Selective Proximal Vagotomy Research Articles

The effect of vagotomy and gastrectomy on the lower esophageal sphincter motility

The motor activity of the canine lower esophageal sphincter (LES) was studied under conscious states by means of the strain gage transducer, and gastroesophageal reflux was investigated after injection of the contrast medium through the silastic tube inserted in gastric fundus by x-ray. The motor activity and function of LES were observed in the dogs with selective proximal vagotomy (SPV), truncal vagotomy (TV) and TV + gastrectomy. Results were summarized as follows; 1. In the postprandial period, so called receptive relaxation was observed in gastric body, and tonic contraction was observed in LES. On the other hand, the occurrence of the LES contraction was consistent with gastric periodic motor activity in the interdigestive state. It was found that such a contractile pattern of LES and gastric body prevented the reflux of gastric juice from stomach to esophagus in the digestive and interdigestive state. 2. In the postprandial period, the tonic contraction of LES was inhibited by the venous injection of atropine sulfate. Mechanisms of digestive contractile activity of LES were mainly regulated by cholinergic nerve. 3. After SPV and TV, the motility of LES and gastric body was disturbed. Namely, receptive relaxation disappeared, and tonic contraction was observed in gastric body, but the relaxation of the LES was found after ingestion. These findings suggested that discordant LES contractiles with the contraction of the gastric body after vagotomy produced a gastroesophageal reflux. 4. After TV + gastrectomy, the synchronous motor activity of the LES, remnant stomach and duodenum disappeared. Namely, it was thought that the reflux esophagitis occurred after gastric surgery with vagotomy and lymphnodes dissection was caused by the duodenal juice reflux to remnant stomach and esophagus.

Pyloroplasty and motile functions of the stomach and duodenum

Mongrel dogs were prepared by attaching 2 and 1 silver needle bipolar electrodes on the gastric antrum and bulbus of the duodenum, respectively. Among the obtained active potential from these dogs at chronic stage, investigations were performed mainly on the discharge frequency of spikes, propagation pattern of electrical excitation, and relationship of the stomach and duodenum. In addition, barium was loaded as the stomach contents and extraction dynamics of the loads were observed radiologically. The following was these investigations concerning about the pyloroplasty and motile functions of the stomach and duodenum. Experimental methods 1) Electromyography and extraction dynamics of stomach contents were observed in no treated control dogs. 2) Heineke-Mikulicz type pyloroplasty, Finney type pyloroplasty, or pylorectomy was performed on the above described control dogs. Electromyographical comparison was made among the types of pyloroplasty. 3) Dogs subjected to selective vagolysis (SV), selective proximal vagotomy (SPV), or gastric transection (Tr) were divided into groups with and without pyloroplasty. Electromyography and extraction dynamics of stomach contents were observed in these groups of animals. Results 1) In the control dogs, the mean discharge frequency of spikes in the gastric antrum at fasting time was 4.86 cycle/minute. The spikes propagated to the pyloric side periodically. The discharge frequency of spikes was reduced by the load of stomach contents which took about 120 minutes to be extracted. 2) When the types of pyloroplasty were compared, smaller electromyographical changes were obtained in dogs subjected to Heineke-Mikulicz type pyloroplasty. 3) Pyloroplasty did not affect the discharge frequency of spikes at fasting time, whereas, high incidences of antiperistaltic propagation pattern of electrdcal excitation were observed in dogs subjected to SPV. 4) When stomach contents were loaded, drainage effects of pyloroplasty were suggested from the discharge frequency of spikes, propagation pattern of electrical excitation, and findings in extraction dynamics of the stomach contents. In the dogs subjected to SPV, pylorplasty induced no significant fluctuations in the discharge frequency of spikes. Dogs subjected to Tr showed no improvement in the frequent antiperistaltic propagation pattern of electrical excitement after the pyloroplasty. 5) By pyloroplasty, the frequency of simultaneous generation of spikes in the gastric antrum and duodenum was decreased in the SV and Tr groups, while it was increased in the SPV group.

Xenopsin- and neurotensin-like peptides in gastric juice from patients with duodenal ulcers.

Using an anti-serum directed against the COOH-terminal region of neurotensin and an anti-serum raised xenopsin in radioimmunoassays, the presence of neurotensin- and xenopsin-like immunoreactivity in Sep-pak extracts of human gastric juice was demonstrated. An anti-serum directed against the NH2-terminal to central residues of neurotensin and an anti-serum directed against a conformation, present only in the intact peptide, did not detect immunoreactivity in the juice. Infusions of pentagastrin at doses of 0.75 micrograms kg-1 h-1 and 1.5 micrograms kg-1 h-1 resulted in significant (P less than 0.05) increases in the total amount of xenopsin-like, but not neurotensin-like, immunoreactivity released in the juice compared with basal release. No significant differences in the release of xenopsin- or neurotensin-like immunoreactive were observed between patients with selective proximal vagotomy and patients without operation. Analysis by gel permeation chromatography and high performance liquid chromatography demonstrated that both the neurotensin- and xenopsin-like immunoreactivity was heterogeneous and an increase in molecular complexity on pentagastrin-stimulation was observed. As both neurotensin and xenopsin inhibit gastric exocrine activity, the presence of immunochemically related substances in gastric juice may have physiological relevance.

Is it really more difficult to treat prepyloric ulcers?

Prepyloric and duodenal ulcers have some common characteristics: gastric acid secretion is increased and there is an association with blood group O. Many, therefore, have considered prepyloric ulcers to be a variety of duodenal ulcer disease. From an anatomical point of view, however, prepyloric ulcers are clearly gastric ulcers. After proximal selective vagotomy, the recurrence rate is very high, amounting to more than 30% in 5 years; this is significantly higher than the rate for duodenal ulcers. Better results are obtained in prepyloric ulcers, if vagotomy is combined with a drainage procedure. In recent years, some evidence, primarily from Scandinavia, has accumulated indicating that prepyloric ulcers are more resistant to treatment with histamine H2-receptor antagonists than duodenal ulcers or ulcers located in other parts of the stomach. In addition, the recurrence rate is particularly high in prepyloric ulcers. One must, however, consider that not only have all of these studies included relatively small numbers of patients, but also the prepyloric ulcer healing rates in other studies were similar to those observed for both duodenal ulcers and ulcers located elsewhere in the stomach. Prospective studies with large numbers of patients are, therefore, necessary before a clear-cut conclusion can be reached. There are several reasons why prepyloric ulcers could be more resistant to treatment. Impaired gastric emptying, duodeno-gastric reflux or chronic gastritis, especially in conjunction with Campylobacter pylori infection, must be considered. At present, one can only speculate on the validity of any of these hypotheses.

Pyloric motor activity and function with special reference to pyloroplasty after vagotomy

Using adult mongrel dogs, pyloric motor activity and gastric emptying observed by phototransducer (P.T.) under anesthesia and by strain gage transducer (S.G.T.) under consciousness. Pyloric motor activity and function were investigated in the dogs with distorted pylorus after instorations of Daclon tube, pyloric resection and pyloric stenosis. The pyloric sphincter responses to gastrin, pancreozymin, secretin, glucagon, atropine, morphine, naloxone and enkephalin administrated intravenously were observed. Gastroduodenal motor activity in relation to the changes of gastrointestinal hormone levels were measured before and after truncal vagotomy (TV) and selective proximal vagotomy (SPV) with or without pyloroplasty. Results are summarized as follows; 1. The pyloric motility recorded by P.T. was well correlated with the contractile activity recorded by S.G.T. under the anesthesia, although the pylorus was never completely closed and showed tonic movements. 2. The pyloric motor activity under the consciousness was different from gastric and duodenal motor activity. 3. After SPV, the gastrin responses to the test meals were significantly increased so that the pyloric motility was disturbed. The fact mentioned above, the pyloric functional disorder after the SPV was partly due to the hypergastrinemia. Pyloroplasty for the SPV inhibited the serum gastrin level. It was suggested that the pyloroplasty for the SPV was necessary to prevent possible hypergastrinemia after SPV.

Serum group I pepsinogens during insulin and pentagastrin tests in unoperated and vagotomized duodenal ulcer patients.

The level of serum group I pepsinogens (PG I) has been studied during the conventional insulin-pentagastrin test in 29 duodenal ulcer (DU) patients before and 2 months after proximal selective vagotomy (PSV) and in 31 unoperated DU patients. The mean basal serum PG I level was 191.6 +/- 15.4 micrograms/l (mean +/- SEM) before and 143.7 +/- 24.0 micrograms/l after PSV. A significant increase in mean serum PG I above the initial value was found both in unoperated DU patients and in patients after PSV 1 h after insulin injection. In 29 PSV patients the mean serum PG I showed a paradoxical decrease during the 2nd h after insulin injection, and the mean postvagotomy serum PG I 2 h after insulin injection was significantly (p less than 0.01) lower than the respective preoperative value in the same patients, and the value was close to the basal serum PG I. The low level of serum PG I 2 h after insulin injection in vagotomized patients may reflect the deprivation of the reduced store of PG I in the absence of normal vagal tone. Both the basal serum PG I and serum PG I response during insulin-induced hypoglycaemia showed an overlap between unoperated and vagotomized DU patients. Therefore, serum PG I analyses during the insulin test cannot replace acid secretion tests in the assessment of the completeness of vagotomy.

Reduction of Postprandial Hyperglycemia by Guar Gum in Symptomatic Patients 5–10 Years following Proximal Selective Vagotomy

The effects of guar gum on postprandial blood glucose concentrations in patients with postprandial symptoms (3 had dumping) 5–10 years after proximal selective vagotomy were studied. Eight subjects ingested 150 ml of a 50% glucose solution containing 5 g of guar gum and 7 subjects ingested 150 ml of a 50% glucose solution containing 5 g of wheat flour as placebo. Fifteen asymptomatic patients served as the control group. The results showed that guar gum decreased the postprandial rise and also slowed down the reversion of blood glucose concentrations to fasting levels. Changes of postprandial blood glucose concentration are one of the indicators of the unknown mechanism of the postprandial symptoms in patients after proximal selective vagotomy.

選択的近位迷走神経切離術後の再発原因に関する実験的研究 特にアドレナリン刺激の影響について

SPV後の再発原因となる因子の1つとして交感神経系に着目し, アドレナリン刺激 (静注: 0.5μg/kg/min, 皮下注: 13μg/kg) を実験犬24頭に施行, 血清ガストリン値および胃酸分泌量を測定した. アドレナリン刺激によって門脈血および末梢血血清ガストリン値は刺激前値に比べて, それぞれ最高28.5%, 26.7%上昇した. またSPV後にはさらに最高68.4%, 60.0%上昇した. 胃酸分泌量もSPV後にはコントロール犬に比べて増加した. その結果SPV後にはアドレナリン刺激によって, 酸分泌, ガストリン放出が増大することから, 再発の一因として交感神経系が関与していることが示唆された.

A CASE OF SPLENIC PSEUDOCYST ASSOCIATED WITH CALCIFICATION

The patient was a 57-year-old woman who visited our hospital with the cheif complaint of tarry stool. Hemorrhagic duodenal ulcer was revealed by emergent endoscopy, and she was admitted to the hospital. After admission she had no hemorrhage from the ulcer. Since an image of globular calcification was obtained in the left hypochondrial region on the plain radiograph of the abdomen, abdominal CT, celiac arteriography, etc., were undertaken. On the basis of the diagnosis of splenic cyst, splencetomy and selective proximal vagotomy were carried out as palliative procedures. From the fact that a cavernous hemangioma-like structure in the old stage was revealed in a portion of the wall of the cyst by histopathological examination of the resected specimens, it was strongly suspected that hemangioma was involved in the occurrence of the cyst.

Effect of selective proximal vagotomy without and with pyloroplasty on gastroduodenal motility.

The effect of selective proximal vagotomy (SPV) was examined in six dogs on the gastric emptying of solid food and the motility of the antrum and duodenum (basic rhythm, motility index, and contractile activity percentage). Emptying and motility were also examined in three dogs after additional submucosal pyloroplasty (SMP). Electrical and motor activities were tested in fasted and fed states. The meal consisted of 300 g of standard protein-mixed meal. Determination of gastric emptying by X ray were conducted with the same meal mixed with barium sulfate. All animals showed delayed emptying of solid food after SPV. Antral motility increased nonsignificantly in the digestive state, whereas duodenal motility decreased, resulting in an increased antroduodenal motor gradient. In the interdigestive state the motility of the antrum decreased significantly. Additional SMP normalized the emptying delay, but decreased digestive and interdigestive motility below the normal values. In conclusion, the emptying delay after SPV is caused at least in part by the altered functional condition of the immediate pyloric region.

Methodology for determining the anthrofundal border of the stomach in the surgical treatment of peptic ulcer disease

Special methods allowing during the operation to establish the boundary between the mucous membrane of the body and the antral part of the stomach have an important practical value. Knowledge of gastric secretory topography provides clear performance of organ-saving operations (antrumectomy and selective proximal vagotomy). We propose to "cut out" the gastric stump so that it retains a part of the vagal nerve branches (in the area of cardia, esophagus, along the right gastroesophageal artery) and in its distal part it is represented by the antral part of the stomach.

Role of hyperbaric oxygenation in preoperative preparation of patients with pyloroduodenal ulcers

Although conservative therapy remains the main treatment for duodenal ulcers, however, 20-30% of patients require surgical treatment. In recent years a new operative method - selective proximal vagotomy - has been introduced into the wide surgical practice of pyloroduodenal ulcers treatment. Its performance is connected with the decision on the surgeon's tactics concerning the ulcerous niche: should it be excised or left?

Endoscopic study of the stomach after selective proximal vagotomy in patients with duodenal ulcer.

Forty patients with duodenal ulcer who underwent selective proximal vagotomy (SPV) with pyloroplasty were examined of intestinal metaplasia before operation, with no increase staining methods, before and after operation. Follow-up periods were between 2 and 9 years after SPV. Reduction rates of acid secretion by SPV were 79% in BAO and 62% in MAO. Five patients were observed to have a slight degree of intestinal metaplasia before operation, with no increase after operation. In the remaining 35 patients, staining areas were not observed either before or after operation. The acid-secreting area demonstrated by endoscopic congo red staining tended to become atrophic after SPV. It can be concluded that the reduction of gastric secretion by SPV does not result in rapid development or progress of intestinal metaplasia of the gastric mucosa.

CLINICAL STUDIES OF PERFORATIONS OF THE ALIMENTARY CANAL

Ninety-four patients with perforation of the alimentary canal who were treated in Saiseikai Shiga Hospital during the past five years were studied with regard to diagnosis, treatment and prognosis. Perforations of the stomach and duodenum were caused most frequently by peptic ulcer, while those of the small intestine and colon most commonly resulted from trauma. Perforations of the stomach and duodenum were diagnosed more easily than those of the small intestine and colon, by marked physical signs of peritonitis and a high rate of recognition of free intraperitoneal air. Extended gastrectomy was performed in almost all the cases of peptic ulcer. Selective proximal vagotomy with pyloroplasty was preferred for the other four cases. In all the three cases of gastric carcinoma, gastrectomy was performed. As operative procedures for patients with abdominal trauma, closure of perforated portions and resection of intestine were performed. Colostomy was undertaken in almost all the cases of perforation of the colon. The prognosis of patients with perforation of the alimental tract was good on the whole. Two patients with duodenal perforation died from hemorragic shock or septic shock, and three with colonic perforation died of endotoxin shock.

Risk Factors on the Perforated Peptic Ulcers and Effect of Selective Proximal Vagotomy

Risk Factors on the Perforated Peptic Ulcers and Effect of Selective Proximal Vagotomy

Therapy failures in ulcer drug therapy--what should be done?

In cases of ulcer relapses during drug therapy of duodenal ulcers the therapy has primarily to be checked and, if necessary, rearranged, and a gastrinoma has to be excluded. In case of ulcer complications the indication for operation is given: in cases of uncomplicated recurrences of ulcers the drug therapy may be adapted or reinforced, at least for the first or perhaps a second recurrence. In case of further recurrences, especially after cessation of medication, the operation has several advantages (no lethality of the elective proximal selective vagotomy, short treatment period, less costly) as compared to a life-long drug therapy.

Acid and pepsin responses to graded doses of pentagastrin in duodenal and corporeal gastric ulcer patients before and after selective proximal vagotomy

The dose response curves for acid and pepsin output to increasing intravenous doses of pentagastrin (0.01, 0.02, 2, 8, and 16 μg/kg per hour) were determined in six male patients with duodenal ulcer and six with type 1 corporeal gastric ulcer before and 3 to 6 months after selective proximal vagotomy and excision of the gastric ulcer. The maximal secretory capacity (maximal response) of acid and pepsin was greater in the duodenal ulcer patients than in the corporeal gastric ulcer patients, but the sensitivity of the oxyntic and peptic cells to pentagastrin (the dose required for half the maximal response) was equal for the two ulcer groups. Selective proximal vagotomy reduced the acid response to insulin by 96 to 100 percent. The acid secretory capacity and the sensitivity of the oxyntic cells to pentagastrin was reduced by selective proximal vagotomy to the same extent in the duodenal ulcer patients and the corporeal gastric ulcer patients. Selective proximal vagotomy reduced the pepsin secretory capacity in the duodenal ulcer patients but did not reduce the already low capacity in the corporeal gastric ulcer patients. Selective proximal vagotomy decreased the sensitivity of the peptic cells in both ulcer groups. Similar results were obtained when the dose response curves were analyzed according to Michaelis-Menten kinetics. Our results justify clinical trials of selective proximal vagotomy with complete ulcer excision for treatment of type 1 corporeal gastric ulcer.

Behavior of somatostatin-immunoreactive cells in the gastric mucosa before and after selective proximal vagotomy and pyloroplasty in treatment of gastric and duodenal ulcers

Antral somatostatin-immunoreactive cells (D cells) were counted pre- and postoperatively in 20 patients with duodenal ulcer and in 8 patients with gastric ulcer. Counts were obtained either over a 2-yr postoperative period (duodenal ulcer patients) at intervals of 0.5, 1, and 2 yr or over a ⩾4-yr postoperative period (gastric ulcer patients) at intervals of 1–2 yr. In patients with a normal population of gastrinimmunoreactive cells (G cells), the D cells were within the normal range (mean value 0.53% in duodenal ulcer patients and 0.67% in gastric ulcer patients). High G-cell values were accompanied by high D-cell values (e.g., in gastrin-cell hyperplasia) and low G-cell values were accompanied by low D-cell values. The G-cell to D-cell ratio was 8:1 and 6.6:1 in duodenal and gastric ulcer patients, respectively. After selective proximal vagotomy and pyloroplasty, the following observations were made: (a) the relation of number of G cells to number of D cells remained unchanged; (b) the postoperative rise in G-cell population was accompanied by a rise in D-cell population; (c) hypertrophy of the D cells was apparent as was postoperative hyperplasia, with a postoperative increase in D-cell size. Morphologic coupling of the gastrin-somatostatin system in the antrum is assumed. This is constant in ulcer disease both before and after vagotomy.

Prospective, randomized trial of selective vagotomy with pyloroplasty and selective proximal vagotomy with and without pyloroplasty in the treatment of duodenal, pyloric, and prepyloric ulcers

In a prospective, randomized trial, 161 patients with duodenal, pyloric, or prepyloric ulcer underwent selective proximal vagotomy. Randomization was then performed to determine if the operation was finished (52 patients), if a pyloroplasty should be added (56 patients), or in addition, if the nerves of Latarjet should be divided (53 patients). Prepyloric and secondary gastric ulcers were excised for microscopy; all were benign. Sex, age, site of ulcer, and duration and incidence of complications of the ulcer disease were similar for the three groups. There was one operative death. The postoperative complications did not differ for the three groups. Four patients were lost to follow-up. The average follow-up for the 156 patients was 3 years (range 1 to 8 years). Recurrent ulcer was detected up to 5 years after surgery in 4 of 53 patients who had selective vagotomy with pyloroplasty, in 4 of 53 who had selective proximal vagotomy with pyloroplasty, and in 5 of 50 who had selective proximal vagotomy. Diarrhea was rare and mild or absent. Dumping was twice as common after selective vagotomy or selective proximal vagotomy with pyloroplasty than after selective proximal vagotomy only, but dumping resistant to treatment was recorded in only two or three patients in each group. The overall results (modified Visick scale) were unsatisfactory in 7 patients after selective vagotomy with pyloroplasty, in 4 after selective proximal vagotomy with pyloroplasty, and in 10 after selective proximal vagotomy, mainly because of epigastric pain with or without recurrent ulcer. We conclude that pyloroplasty may cause mild dumping without nuisance to the patient. The rates of recurrent ulcer in long-term follow-up trials are essential for final evaluation of the operations.

Morphology and Function of the Parietal Cells after Proximal Selective Vagotomy in Duodenal Ulcer Patients

The effects of proximal selective vagotomy (PSV) on parietal cell morphology and the degree of gastric inflammation were investigated and correlated with changes in gastric acid secretion and serum gastrin concentrations in 17 duodenal ulcer patients. Endoscopy, acid secretion tests, and blood sampling were performed preoperatively and 2 months, 1 year, and 3 years postoperatively. The mucosal biopsy specimens obtained at endoscopy were analyzed both light- and electron-microscopically. Five healthy persons also underwent gastroscopy and biopsy for comparison. Preoperatively, the duodenal ulcer patients differed significantly from this control group, 33% of whose parietal cells appeared 'secretory'; the corresponding figure for the duodenal ulcer patients was 47%. Two months after the operation the number of secretory parietal cells had fallen to 30%, after which the percentage increased slightly again to 35% 3 years after PSV. A similar phenomenon was observed in the acid secretion capacities, which were maximally depressed 2 months postoperatively and recovered slightly but significantly during the 3-year follow-up period. There was a significant increase in the degree of gastric inflammation after the operation.