Selective Gastric Vagotomy Research Articles

Impaired pancreatic innervation after pyloric transsection in dogs. Reduced pancreatic polypeptide response to insulin hypoglycaemia.

Pancreatic polypeptide (PP) is released by efferent vagal impulses and its secretion is impaired after truncal and selective gastric vagotomy while remaining unchanged after parietal cell vagotomy. In three dogs an innervated antral pouch with transsection of the pylorus was constructed. After this operation the PP response to insulin hypoglycaemia was significantly reduced as compared to the preoperative response. In another four dogs an innervated antral pouch was constructed without transsecting the pylorus. Postoperatively we found that the PP response to insulin hypoglycaemia was unchanged compared to preoperatively. These results seem to indicate that vagal fibres to the pancreas run in close anatomic relation to the pylorus, and their inevitable damage during pyloric transsection results in reduced endocrine pancreatic secretion to vagal stimuli.

Histamine-elicited drinking is dependent upon gastric vagal afferents and peripheral angiotensin II in the rat

While transection of either the anterior (including hepatic) or posterior (including coeliac) vagal trunk failed to alter drinking in response to subcutaneous histamine (0.312–20 mg/kg), selective gastric vagotomy severely attenuated drinking after systemic histamine (1.25–40 mg/kg) in male Sprague-Dawley rats. The dose-response curve for rats with gastric vagotomy was shifted to the right: Vagotomy increased the threshold dose nearly tenfold and more than doubled the ED 50. Because the effect of vagotomy on histamine-elicited drinking was not mimicked by cholinergic blockade of vagal efferents using atropine methyl nitrate (10 mg/kg), these results demonstrate that gastric vagal afferents are necessary for a normal drinking response to systemic histamine. When gastric vagotomy was combined with intragastric SQ14,225 (to inhibit the conversion of peripheral angiotensin I to angiotensin II) drinking after systemic histamine was abolished. These results suggest that gastric vagal afferents and angiotensin II are necessary for systemic histamine to elicit drinking in the rat.

Recovery of gastric acid after vagotomy with and without a drainage.

This study tests the possibility that the difference in acid reduction after parietal cell vagotomy (PCV) and selective gastric vagotomy with a drainage (SGV + D) could be explained by differences in the secretion recovered rather than by real secretory differences. A method for estimating the completeness of aspiration during gastric function tests using the isotope Na251CrO4 as an inert marker is described. The method was used in patients with the two types of vagotomy and the recovery of gastric secretion was more complete after PCV (89.7%) than after SGV + D (75.1%). This difference may substantially account for the apparent difference in reduction of acid secretion after the two operations. The pyloroplasty supplementing the SGV is probably responsible for a pyloric loss causing a lower recovery after this operation.

Selective Gastric Vagotomy and Drainage for Duodenal Ulcer

From 1964 to 1968 selective gastric vagotomy (SGV) and drainage was performed in 174 patients. Of these, 105 patients were followed-up 10-13 years after operation; 56 were dead. Ulcers recurred in 18 patients. The cumulated recurrence rate after 13 years (life table method) was 15% (95% confidence limits: 8-23). The method for drainage was usually either a Heineke-Mikulicz or a Finney pyloroplasty. There was a significantly higher risk of ulcer recurrence in the group that underwent Heineke-Mikulicz drainage procedures. The incidence of dumping and diarrhea had not changed during a five-year follow-up period. Two patients were slightly anemic. No patient was iron-deficient. Apart from two recurrent ulcers, gastroscopic examinations in 36 patients revealed no major changes, and biopsy specimens showed slight to moderate chronic atrophic gastritis in most cases. Visick grading showed 77% of the ulcers in Grade I + II, 19% in Grade VI. It is concluded that SGV has no place in the elective treatment of duodenal ulcer. Two alternatives are suggested.

A non-invasive test for completeness of vagotomy to the pancreas

A new test for completeness of vagotomy to the pancreas was developed. It is based upon the post-absorptive consequences of the absence of cephalic insulin secretion in vagotomized rats. Rats were divided into three groups: in group I, rats were submitted to a truncular vagotomy; in group II, rats underwent a selective gastric vagotomy; group III was a control group. The test was performed when operated rats had recovered from surgery. All rats were fasted from 9 a.m. to 14 a.m. At 14 a.m. (t=0) they were offered 1 ml of a 50% glucose solution and the small amount of urine secreted between t=10 and t=20 was tested for glucose using a reactive strip. Glucose was detected in rats of group I only. This test seems to be a good index of vagotomy to the pancreas; it is easy, inexpensive and non-terminal.

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.

Selective gastric vagotomy by cryonecrosis

Selective gastric vagotomy by cryonecrosis

Gastroesophageal sphincter pressure and serum gastrin studies following food intake before and after vagotomy for duodenal ulcer.

Gastroesophageal sphincter pressure (GESP) and serum gastrin concentration (SGC) were determined in the basal state and after a protein meal in six patients with duodenal ulcer (DU), six patients after parietal cell vagotomy (PCV), six patients after selective gastric vagotomy plus drainage (SGV + D), and six patients after selective gastric vagotomy plus precise antrectomy (SGV + A). No correlation in the resting state between GESP and SGC was observed. After food ingestion, DU patients showed a sustained rise in GESP which lasted up to the end of the experiment. The vagotomized patients, however, showed no rise in sphincter pressure after food intake--rather a tendency to a decrease in pressure occurred. On the contrary, SGC rose significantly after food ingestion in patients with SGV + D or PCV, while in DU patients this rise was less significant. Patients with vagotomy and antrectomy showed no rise in SGC. These results do not suggest that SGC and extrinsic vagal innervation in the resting state play a significant role in the maintenance of the tone of GES. After food ingestion an interaction may occur between intact vagal innervation and rise in SGC in order to obtain an adequate rise in GESP.

Gastroesophageal sphincter pressure and serum gastrin studies following food intake before and after vagotomy for duodenal ulcer.

Gastroesophageal sphincter pressure (GESP) and serum gastrin concentration (SGC) were determined in the basal state and after a protein meal in 6 patients with duodenal ulcer (DU) 6 patients after parietal cell vagotomy (PCV) 6 patients after selective gastric vagotomy plus drainage (SGV + D), and 6 patients after selective gastric vagotomy plus precise antrectomy (SGV + A). No correlation in the resting state between GESP and SGC was observed. After food ingestion, DU patients showed a sustained rise in GESP which lasted up to the end of the experiment. The vagotomized patients, however, showed no rise in sphincter pressure after food intake--rather a tendency to decrease in pressure occurred. On the contrary, SGC rose significantly after food ingestion in patients with SGV + D or PCV, while in DU patient this rise was less significant. Patients with vagotomy and antrectomy showed no rise in SGC. These results do not suggest that SGC and extrinsic vagal innervation in the resting state play a significant role in the maintenance of the tone of GES. After food ingestion an interaction may occur between intact vagal innervation and rise in SGC in order to obtain an adequate rise in GESP.

The aarhus county vagotomy trial

AbstractSince June, 1972 a total of 830 patients have been consecutively operated on electively for proven duodenal, pyloric, or prepyloric ulcer. For various reasons 82 patients were excluded, while 748 were allocated at random to parietal cell vagotomy (PCV) or selective gastric vagotomy (SGV). A drainage (D) was added to PCV in 68 patients with gastric retention. In the SGV group, a secondary randomization between antrectomy (A) and drainage was performed when the peak acid output response to pentagastrin was 45 mEq/h or more. The patient material comprised 353 SGV + D, 54 SGV + A, 273 PCV, and 68 PCV + D. Five patients died postoperatively from cardiovascular disease (0.7%). Splenectomy was necessary in 4%, and 5 patients sustained an operative perforation of the esophagus or the cardia which was recognized at operation and successfully treated. Postoperative complications were evenly distributed, but were milder after PCV. Only 11% of patients with PCV were discharged from the hospital later than the 10th postoperative day, compared to 19% of patients after SGV + D. No patients had postoperative gastric retention after PCV, while 20 patients had retention after SGV + D, and in the following years vomiting was less frequent after PCV than after the other operations. A transitory dysphagia occurred in 9% of all patients and subsided in a couple of months. Dumping occurred significantly less frequently after PCV without D than after the other operations and was considerably milder. The addition of D to either PCV or SGV led to a similar incidence of dumping. It is concluded that it is unnecessary to add a drainage procedure to PCV and that PCV without D is followed by milder postoperative complications and a lower rate of sequelae than other operations for duodenal ulcer.

Abolition by selective gastric vagotomy of the influence of water temperature on water intake: Mediation via enhanced gastric clearance

Female rats had water available for 20 min/day. The temperature of the water alternated between cool (5°C) and warm (35°C) water days. Intact rats drank 33% less on cool water days. After bilateral gastric vagotomy intake on warm water days fell such that there was no longer any differential thermal influence on water intake. In a second experiment intact rats retained 38% less of the ingested water in their stomachs 20 min after the start of a cool water drink as compared to a warm drink. With bilateral gastric vagotomy, warm water gastric retention was reduced such that there was no longer any differential thermal influence on gastric retention. Thus, cool water appears to elicit a reflexive inhibition of vagal efferents to the upper gastrointestinal tract as a result of which gastric clearance accelerates and water intake is suppressed.

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.

Experiments in animals in connexion with truncal and selective gastric vagotomy in rats (author's transl)

The effects of truncal and selective gastric vagotomy after 9 h ligation of the pylorus were studied on Shay rats. No statistically significant difference was found with regard to gastric tonicity, volume of gastric juice, its pH value, nor with regard to the acidity. However, the size of the stress ulcers showed evident differences; vagotomy of the trunk protects the rat better from developing ulcers than selective vagotomy. By means of additional experiments e.g. ligature of the left gastric artery, truncal and selective gastric vagotomy performed simultaneously, we could demonstrate that this statistically significant difference is due to devascularisation of the lesser curvature of the stomach.

Influence of Parietal Cell Vagotomy and Selective Gastric Vagotomy on Gastric Emptying Rate and Serum Gastrin Concentration

Gastric emptying of a solid meal and serum gastrin concentration were studied in 26 patients with duodenal ulcer disease before and after parietal cell vagotomy (PCV), selective gastric vagotomy with drainage (SGV + D), or parietal cell vagotomy with drainage. PCV had no significant effect on gastric emptying rate, whereas emptying was significantly delayed after SGV + D. The integrated gastrin output 60 to 300 min after the test meal was insignificantly altered after PCV, but significantly increased after SGV + D. It is concluded that the drainage procedure did not normalize the disturbed gastric emptying after SGV. The prolonged hypergastrinemia period after food stimulation may reflect stasis.

The Effect of Insulin on Food-stimulated Secretion of Gastrin after Parietal Cell Vagotomy and Selective Gastric Vagotomy

Serum gastrin concentration was measured in 11 patients with Parietal Cell Vagotomy and Drainage (PCV + D) and in 11 patients with Selective Gastric Vagotomy and Drainage (SGV + D) in the basal state, after a meal, and after a meal in combination with insulin-hypoglycaemia. Insulin had an early and transitory, but significant, inhibitory effect on the food-induced rise in serum gastrin concentrations. This inhibition was the same whether the patients had a PCV + D or SGV + D, indicating that it has no relation to the vagal innervation of the antrum. In the second hour after the meal the integrated gastrin output was significantly higher when insulin was added to a meal in patients with PCV + D but not in patients with SGV + D. This may indicate a certain, possibility sensitizing, effect of the vagal antral nerves.

Antral Denervation in Parietal Cell Vagotomized Dogs

In ten Heidenhain pouch (HP) dogs who previously had undergone parietal cell vagotomy (PCV) with gastroduodenostomy, the antral nerves were cut, and the PCV thus converted to a selective gastric vagotomy (SGV). Mean gastric emptying rate was unaffected but antral motility changed considerably, the stomach became big and slack, and the emptying of a food-barium meal became purely passive. While the duodenal bulb was often filled with gastric content before antral denervation, this happened very seldom afterwards. Fasting, food-stimulated and 24-hour HP acid secretion increased significantly after denervation, but this was not accompanied by any significant changes in serum gastrin concentration. This indicates that other factors than gastrin must be responsible for the increased HP acid response to a meal after antral denervation.

Parietal cell (highly selective or proximal gastric) vagotomy for peptic ulcer disease

Parietal cell vagotomy has been in clinical use for 7 years in elective treatment of nonobstructive duodenal ulcer, and for even a shorter period for complicated cases and for gastric ulcer The evolution of the surgical technique has not yet come to an end and the ability to perform the procedure is still improving. It can therefore be questioned, if this operation is yet ripe for a realistic clinical trial, and the great variation in recurrence rate reported in pilot series as well as in prospective randomized clinical trials points to the possibility that we will have to wait several years before the anticipated mean recurrence rate is known. At present it can be stated that even if gastric emptying is not quite undisturbed, the addition of a drainage procedure in nonobstructive cases is unnecessary. The same may be true in some patients with pyloric obstruction. Furthermore, the mortality rate is very low and the incidence of moderate-to-severe dumping and diarrhea is virtually nil.

A Review and Evaluation of Operative Procedures Used for Chronic Duodenal Ulcer

No one operation has emerged as the one to be used for all patients requiring surgery for chronic duodenal ulcer, although currently the favorite appears to be truncal vagotomy with antrectomy. Selective and proximal gastric vagotomy may, however, assume an increasingly important position in the armamentarium of the surgeon.

Gastric Motility and Emptying following Parietal Cell Vagotomy and Selective Gastric Vagotomy

After parietal cell vagotomy in dogs antral motility and gastric emptying time is unaffected. Addition of a drainage procedure changed the motility considerably by decreasing the force of contractions and diminishing the number of peridtaltic waves. After cutting the antral nerves complete atony occurred, but emptying rate was unaltered as the contrast meal passed passively through the anastomosis. Selective gastric vagotomy without drainage caused atony and significantly prolonged emptying time.

Effects of selective gastric vagotomy and pyloroplasty on oral and intravenous glucose tolerance and insulin secretion.

In peripheral and portal venous blood, the immunoreactive insulin (IRI) and glucose levels in response to orally and intravenously administered glucose were measured in 14 patients with selective gastric vagotomy and pyloroplasty (SGV+P) and in 17 control subjects with other abdominal surgery. After intravenously administered glucose, the insulin and the glucose levels were nearly identical in both groups. After orally administered glucose, there were remarkable differences. Despite their early postoperative situations, and in contrast to the control patients, the SGV+P subjects showed no hyperglycemia. The measurements of IRI in the portal vein suggested that in SGV+P patients, the response of the islet cells is accelerated. In patients with SGV+P, the release of an insulinotropic intestinal factor and the preserved vagal innervation of the pancreas may be responsible for the accelerated insulin response of the undisturbed glucose tolerance.