Selective Proximal Vagotomy Research Articles

Prophylactic gastric operations in uremic patients prior to renal transplantation

AbstractGastroduodenal bleeding or perforation occurs in 3.5–60% of renal transplant patients. The mortality rate of this complication ranges from 35 to 75%. Experience with 61 chronic hemodialysis patients being prepared for renal transplantation is presented. History, endoscopy, and gastric analysis disclosed a considerable risk of gastroduodenal complications in 20 transplant candidates, defined as a history, presence, or sequelae of ulcer disease or hyperchlorhydria. These 20 patients underwent prophylactic gastric surgery. Lower risk patients were treated by selective proximal vagotomy, and higher risk patients underwent a selective gastric vagotomy plus Billroth I gastric resection. Follow‐up for 11–34 months showed no mortality and no gastroduodenal symptomatology. A kidney transplant has been performed to date in 15 of the patients who had prophylactic gastric surgery, and none of them developed gastroduodenal complications during follow‐up of 6–30 months after transplantation. Of 29 patients who were not believed to be at risk for gastroduodenal complications and did not have prophylactic gastric surgery, 3 bled from duodenal ulcers after renal transplantation, 1 with fatal outcome.

Effect of Selective Proximal Vagotomy on Food-Stimulated Gastric Acid Secretion and Gastrin Release in Patients With Duodenal Ulcer

We studied effects of selective proximal vagotomy on food-stimulated acid secretion and gastrin release in 7 duodenal ulcer patients. Food-stimulated acid secretion was evaluated by sham feeding patients and by infusing food directly into their stomachs. Vagotomy reduced sham feeding-stimulated acid secretion from 28.2 +/- 4.6 to 1.2 +/- 0.7 meq/hr (95% reduction) whereas infused food-stimulated secretion was decreased from 36.1 +/- 4.6 to 17.9 +/- 5.5 meq/hr (50% reduction). In contrast to the reductions in acid secretion, the gastrin response to infused food doubled after surgery. Although selective proximal vagotomy reduced the rate of acid secretion in response to infused food and also reduced by 64% the peak secretory capacity (peak acid output to pentagastrin), fractional secretion (i.e., the secretion rate in response to infused food expressed as a percentage of the peak secretory capacity) increased significantly after vagotomy from 63 +/- 7% to 91 +/- 11%. This increased fractional secretion in response to infused food was probably a result of exaggerated gastrin release after vagotomy.

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.

Results of selective proximal vagotomy for gastroduodenal ulcer (author's transl)

Between 1971 and 1976 selective proximal vagotomy (SPV) was performed in 526 patients with uncomplicated duodenal ulcer and in 37 with gastric ulcer. The operative mortality was 0.18%. The post-operative course was without complication in 90%. One to five years post-operatively 75% of patients with duodenal ulcer were largely without symptoms (Visick I and II), a dumping syndrome was present in 6.5%, diarrhoea in 4.2%, gastric outlet stenosis in 1% and recurrent ulcer in 10.9% of patients who could be re-examined. Recurrent ulcer occurred in eight of 36 patients re-examined after SPV for gastric ulcer. Results of SPV so far have shown it to be a useful alternative to gastric resection in the treatment of duodenal ulcer. But its place in the treatment of gastric ulcer remains undecided.

Gastric motility after selective proximal vagotomy

Gastric motility after selective proximal vagotomy

Gastric motility after selective proximal vagotomy

Effects of vagotomy on gastric motor activity were studied on 39 patients after vagotomy for gastric or duodenal ulcer by fluoroscopic examination and by monitoring of intragastric pressure using a balloon introduced into the stomach. These patients were divided into three groups according to types of vagotomy; selective proximal vagotomy (SPV), selective vagotomy (SV) and atypical selective proximal vagotomy. In atypical SPV, dorsal antral branches of vagal gastric nerves were sacrificed in addition to conventional SPV because of local conditions around the ulcer. In patients after SPV or atypical SPV, no gastric stasis was observed on fluoroscopic examination. However, marked gastric stasis with delayed emptying was a constant finding in patients after SV, especially at the early postoperative period. In recording of intragastric pressure, basic peristaltic waves of a 20-second rhythm were observed following inflation of the balloon in all patients after any type of vagotomy. In addition, an alternation of active and resting periods of motor activity and confluence of large waves at the end of active period were observed as characteristoc findings in patients after both SPV and atypical SPV. The large waves were considered to coincide with active propulsive movements seen on fluoroscopy in these patients. The results in this study confirmed that good gastric motility could be preserved in patients after SPV and even after atypical SPV.

Effect of selective proximal vagotomy and truncal vagotomy on gastric acid and serum gastrin responses to a meal in duodenal ulcer patients.

To assess the effectiveness of selective proximal vagotomy (SPV) in reducing the acid response to food, we have compared pre- and postoperative gastric acid and serum gastrin responses to a meal in 11 duodenal ulcer patients with intractable pain treated by SPV, with those of seven ulcer patients with gastric outlet obstruction treated by truncal vagotomy and drainage (TV + D). Acid secretion was measured by an intragastric titration method which measures acid response to food within the stomach (5% amino acid meal) adjusted to various pH levels (5.5, 2.5, and 1.5). Studies were performed before and two to six weeks after operation. The preoperative intragastric acid output (IGAO) was about 50% of maximal acid response to Histalog. The mean preoperative IGAO at pH 5.5 For 11 SPV patients was 17.4 +/- 3.1 mEq/hour; this was decreased by 72% to 4.3 +/- 1.1 mEq/hour after operation. The mean IGAO at pH 5.5 in nine patients treated by TV + D was 21.6 +/- 3.4 mEq/hour; this was decreased by 67% to 7.3 +/- 2.1 mEq/hour. Gastrin levels were significantly higher in postop than in preop SPV PATIENTS EVEN THOUGH PH values were constant. Gastrin levels were higher in postop TV + D patients than in postop SPV patients. This study demonstrates that acid reduction achieved by SPV is reliable and at least comparable with that achieved by turncal vagotomy. Postoperative elevation of gastrin in the SPV patients suggests that the vagus may release a humoral inhibitor of gastrin release from the gastric fundus; there may also be a further direct vagal inhibitor of antral gastrin release.

Effect of selective proximal vagotomy (SPV) on serum concentration of GIP, insulin and gastrin in duodenal ulcer patients (DU)

Effect of selective proximal vagotomy (SPV) on serum concentration of GIP, insulin and gastrin in duodenal ulcer patients (DU)

Side effects of proximal selection vagotomy on the esophagus. I. Effects on the esophageal blood circulation (author's transl)

The influence of the proximal selective vagotomy (PSV) with following skeletisation of parts of the esophagus on its circulation was investigated in an animal experimental study. Among the 6 dogs with PSV and skeletisation of the esophagus up to the upper thorax apertura one was seen with necrosis and perforation in the distal part of the esophagus. The last 5 dogs and the 4 dogs in which after the PSV only the denudation of the distal part of the esophagus was carried out no signs of circulatory disturbance were seen. The blood circulation in human esophagus, as described in the literature, and the transfer of the results from dogs to human is discussed. An enlarged skeletisation of the esophagus in order to improve the completeness of the PSV does not harm blood circulation.

Effects of selective proximal and truncal vagotomy on canine gastric motility (author's transl)

With the use of electromyography and intraluminal pressure recording of the pylorus, the effect of selective proximal and truncal vagotomy on the gastric motility was investigated in 10 dogs. The results are summarized as follows: 1. Control dogs showed regular discharge intervals with elevation of intrapyloric pressure coinciding with the action potentials. There was seen no occurrence of antiperistalsis. 2. Selective proximal vagotomy resulted in the prolongation of discharge intervals along with slight decrease in the incidence of action potentials. The rate of antiperistalsis was 4.4%. Besides, the rate of pyloric contraction also showed a tendency of slight decrease. 3. Truncal vagotomy lead to the prolongation of discharge intervals and decrease in the incidence of action potentials, though these changes were milder than those after selective proximal vagotomy. The incidence of antiperistalsis was 6.8% which was higher than the one after selective proximal vagotomy. Eelvation of intrapyloric pressure did not necessarily took place coinciding with the action potentials. Intrapyloric pressure as well as the incidence of pyloric contraction showed a marked decrease when compared with those of the control and selective proximal vagotomy dogs. Out of these results, it is concluded that the selective proximal vagotomy is superior to the truncal vagotomy when viewed from the preservation of the gastric motility.

AN ELECTROMYOGRHIC STUDY OF THE STOMACH AFTER SELECTIVE PROXIMAL VAGOTOMY IN DOGS

To clarify the gastric motor function after selective proximal vagotomy (SPV) by electromygoraphy in dogs, I designed the following experimental groups; Group I is the control, untreated dogs; Group II is SPV operated dogs; Group III is selective antral vagotomy (SAV) operated dogs.The gastric electromygoram was taken from fasted food stimulated, and insulin stimulated dogs in each groups, and the recording was begun two weeks after theoperation.The results are summarized as follows.1) The were no significant differences in discharge intervals before and after food and insulin stimulation in all groups.2) The propagation velocity was delayed markedly in SPV- and SAV-operated dogs compared to the untreated dogs before stimulation.3) It seemed to be that the delay of propagation velocity at fasting, was more prominent in SAV than in SPV.Therefore, it is suggested that antral branch might play an important role on the gastric motor function.

Selective Proximal Vagotomy for Duodenal Ulcer in Children

Selective Proximal Vagotomy for Duodenal Ulcer in Children

Gastroduodenal ulcer: surgical therapy (author's transl)

In evaluating results after surgical therapy of gastroduodenal ulcer, lethality and recurrency rate are important criteria, but a third "quality of life" should be considered equally important. Proximal selective vagotomy seems to carry a very small lethality risk and extremely good "qualities of postoperative life." A minority of patients may need two "surgical steps" to achieve a good end result. The modified Burge test has been found useful in a prospective study. As to technical details, the denudation of the subdiaphragmatic esophagus over a distance of 5--6 cm seems paramount for achieving a good proximal vagal denervation of the acid-secreting area of the stomach.

The technique of proximal selective vagotomy (author's transl)

A standard technique of proximal selective vagotomy is described (PSV) that has proved reliable and safe in a broad multicenter clinical trial. We proceed in six steps: (1) determination of the antral-fundic boundary by anatomic criteria; (2) preliminary vagomotor electrotest; (3) identification of the nerve trunks and branches to be preserved; (4) dissection of the lesser curvature; (5) dissection of the cardia and of the intraabdominal esophagus up to 6 cm above the cardia; and (6) intraoperative assessment of completeness by the vagomotor electrotest. PSV is usually carried out without a drainage procedure.

Stimulation of H+ secretion and serum gastrin by intra-operative electrical vagal stimulation before and after proximal selective vagotomy (author's transl)

H+ secretion and gastrin concentration were measured before and after electric vagal stimulation during proximal selective vagotomy in 29 patients with duodenal ulcers. Before vagotomy, H+ secretion and serum gastrin concentration significantly rose after stimulation, while after complete vagotomy H+ secretion remained below basal values, although serum gastrin concentration was significantly increased. These results indicate that without vagal innervation there is no gastrin secretion within physiological levels. The method is suitable for testing the completeness of the vagotomy, the results not agreeing with those obtained by pressure measurements (Burge's method).

Surgical prophylaxis of gastroduodenal complications associated with renal allotransplantation

AbstractFrom 1971 to 1975, 226 patients received kidney allografts, and prophylactic ulcer surgery was regularly performed prior to kidney transplantation in those who had a history of previous ulcer, symptoms of peptic ulcer, a demonstrable ulcer on x‐ray or endoscopy, gastric acid hypersecretion, or a temperament conducive to the development of peptic ulcer. The results of this prophylactic program were compared with those of the previous period from 1964 to 1970 when prophylactic ulcer surgery was not used in 77 kidney allograft recipients, and with those of the concurrent period obtained in 194 recipients who did not receive surgical prophylaxis. Initially, the prophylactic operation was truncal vagotomy with pyloroplasty, then it was proximal selective vagotomy (PSV) without pyloroplasty, and finally it was selective gastric vagotomy with pyloroplasty (SGV+P). The incidence of gastroduodenal complications in patients who did not receive prophylactic ulcer surgery was 22.1% during the period 1964–1970, and 15.9% during the period 1971–1975; the mortality rates from gastroduodenal complications were 10.4% and 4.6%, respectively. In contrast, only 1 of 32 renal transplant recipients who underwent prior prophylactic ulcer surgery developed a gastrointestinal complication, and there were no deaths in the prophylactic surgery group. Two patients developed fatal ischemic necrosis of the stomach following PSV, which led to the adoption of SGV+P as the prophylactic operation of choice.

The effect of selective proximal vagotomy with and without pyloroplasty on serum gastrin levels and acid secretion after feeding and sham feeding in dogs.

AbstractIn a first operative stage, 4 dogs were prepared with Heidenhain pouches (HP) and 3 with Pavlov pouches (PP), 2 of the latter with an additional esophageal cannula. In a second stage all dogs had a selective proximal vagotomy (SPV), and in a third stage a submucosal pyloroplasty (P). Sham feeding experiments were carried out on the 2 dogs with PP and an esophageal fistula before and after SPV. Feeding tests were performed in all animals after the three operative procedures. Gastrin release after sham feeding increased significantly after SPV, whereas PP acid secretion was abolished. Gastrin release after feeding increased significantly after SPV in both HP and PP dogs. Acid secretion from HP was correlated with the changes in postprandial serum gastrin levels. PP acid secretion was diminished after SPV, in spite of the elevated gastrin levels. Subsequent pyloroplasty induced a significant decrease in the postprandial gastrin levels in both HP and PP dogs. However, acid secretion decreased significantly only in HP dogs.

Effects of various types of vagotomy on electrical and contractile activities of the canine stomach (author's transl)

Thirteen mongrel dogs equipped with four bipolar electrodes and three strain gauges on the anterior wall of the stomach underwent three types of vagotomy: truncal vagotomy (TV)-6 dogs; selective proximal vagotomy (SPV)-3 dogs; and antral vagotomy (AV)-4 dogs. Electrical and contractile activities of the stomach were examined before and after these vagotomies on both the fasting and postprandial states. TV caused an increased incidence of dysrhythmia and a 12 to 33% reduction of the propagation velocity of the basic electrical rhythm (BER). Following feeding, the characteristic waxing and waning pattern of normal gastric contraction was altered to a monotonic steady pattern, increasing overall contraction activity of the pyloric sphincter. These changes seem to be attributable to delayed gastric emptying following truncal vagotomy. SPV reduced the propagation velocity of the BER slightly (2.5-7.3%), preserving the inherent physiological contractile activity in the antrum and pyloric sphincter, and transforming the contractile activity in the corpus to a more monotonic pattern. AV effected a localized monotonic contractile activity in the antral region with no changes discernible in the body and pyloric sphincter. The propagation velocity was not changed significantly by antral vagotomy. The discharge interval of the BER was not altered significantly by these vagotomies.

The role of gastrin in duodenal ulcer surgery

The role of gastrin and of serum gastrin analysis in duodenal ulcer disease and duodenal ulcer surgery is analysed. As far as etiology and pathogenesis are concerned up to now gastrin has never been shown to play a significant role. Neither does it provide any diagnostic help in the typical duodenal ulcer disease (but it will allow for diagnosis of the retained antrum after Billroth II resection and of the Zollinger Ellison syndrome). Gastrin determination therefore is not helpful in the choice of the correct operative procedure for the ulcer disease. In today's clinical practice its major role consists in the control of surgical results. This is illustrated by a prospective randomized study on proximal selective vagotomy with and without pyloroplasty. In these patients serum gastrin analysis has shown that the omission of pyloroplasty is not followed by antral stasis. It furthermore always exhibits the typicel vagotomy profile, although vagotomy is incomplete in the 2-DODG-test.

Vagotomy: Latest Advances

This small paper-bound volume is composed of experimental and clinical contributions of surgeons in the University Poliklinik Hospital, Munich, Germany, relative to the development of selective proximal vagotomy. This form of vagotomy, limited to the parietal cell-bearing areas of the stomach, gives promise of becoming the standard method of vagotomy around the world. Quite correctly, surgeons have not been in a rush to adopt this particular operative procedure, since its long-term results remain unproved. At the present time, the Munich surgical group remains adamant in their insistence on the addition of a drainage procedure to selective proximal vagotomy. The book is a compendium of their experimental evidence in support of both the operation and the addition of a drainage procedure. There is a brief discussion of gastric physiology, mostly provided by several renowned contributing authors. There are very few authors who have contributed to this volume on the subject of