Selective Vagotomy Research Articles

A laboratory appraisal of the effects of truncal and selective vagotomy.

Abstract Maximal acid output and insulin tests were carried out in a series of 56 consecutive patients who had either a truncal or a bilateral selective vagotomy and drainage operation. The results of the insulin tests are discussed in the light of criteria established by several authors. The postoperative reduction in basal and maximal acid output was considered, and also the risk of recurrent ulceration. A comparison of the test results of the two types of vagotomy was made, and no significant difference was found.

Peroperative grading of pyloric stenosis: a long term clinical and radiological follow-up of patients with severe pyloric stenosis treated by highly selective vagotomy and dilatation of the stricture.

Highly selective vagotomy (HSV) is now an accepted form of surgery for uncomplicated duodenal ulcer. Highly selective vagotomy and dilatation has been successfully used in some cases of pyloric stenosis, but many would regard severe pyloric stenosis as a contraindication to this procedure. Eleven patients with severe pyloric stenosis, measured objectively at operation, have been treated by HSV and dilatation of the stenosis and reviewed for periods of up to 3 years. The clinical results, immediate and long term, were good in all cases. Barium studies and histopathological findings were slower to return to normal. With intensive preoperative preparation to restore the tone of the dilated gastric muscle and gentle, controlled dilatation of the stricture, HSV in these patients should be as satisfactory as in those patients with uncomplicated duodenal ulcer.

Coeliac and hepatic nerve function following selective vagotomy.

Abstract In the intact patient insulin hypoglycaemia increases the output of amylase and bile-acids despite the exclusion of acid from the duodenum. This effect is abolished by truncal vagotomy. After selective vagotomy a partial response from the pancreas occurs consistent with preservation of a direct route in the coeliac nerve and the loss of vagally released pancreatic secretagogues. A similar effect in the biliary system could not be demonstrated.

Lesser curve disconnection using a stapling device: highly selective vagotomy made quicker and easier.

A stapling device has been used to disconnect the lesser curve of the stomach during highly selective vagotomy in a consecutive series of ten patients. This modification renders the operation technically easier and quicker to perform. Postoperative recovery was uneventful in all patients, and in the subsequent follow-up period of 7-15 months, no problems relating to the technique were encountered.

Highly selective vagotomy without a drainage procedure in the treatment of haemorrhage, perforation, and pyloric stenosis due to peptic ulcer.

Abstract The good results of highly selective vagotomy (H.S.V.) in the elective surgical treatment of uncomplicated duodenal ulcer led to its use in the treatment of 30 patients who were suffering from complications of peptic ulcer, over a period of 21 months. In the emergency situation it is vital to select for H.S.V. patients who are fit enough to withstand a 1–2-hour operation. Five out of a total of 9 patients with perforated duodenal ulcer were deemed to be suitable for H.S.V. In contrast, H.S.V. was used in the treatment of all 10 patients with haemorrhage (5 patients with duodenal ulcer and 5 with gastric ulcer), because definitive treatment for the ulcer is essential after haemorrhage has been arrested by direct suture. Pyloric stenosis was diagnosed in 15 of 75 patients who came to elective surgery for duodenal ulcer. The diagnosis was made on clinical and radiological grounds and was confirmed at operation. Seven of the 15 patients had concomitant gastric ulceration. All 15 patients were treated by H.S.V. without a drainage procedure. The stenosis was simply dilated digitally. Seven patients who were followed up for at least a year underwent barium-meal examination, which showed that gastric emptying was normal in each case and that there was no sign of recurrent ulceration. There was no operative mortality. None of the patients with haemorrhage bled again after operation. Only 1 of the 30 patients developed gastric retention, which was transient. Of the 14 patients who were reviewed more than 1 year after H.S.V., 11 had a perfect clinical result, 2 were very good, and 1 was ‘fair’ (Visick grade 3). The long-term prognosis should be the same as that of patients who have undergone elective H.S.V. Granted a modicum of case selection, H.S.V. is a safe operation in the treatment of emergencies such as haemorrhage or perforation. In pyloric stenosis H.S.V. preserves and makes use of the stomach's compensatory mechanisms of hypertrophy and hyperperistalsis, whereas both gastrectomy and vagotomy with drainage destroy them. Vagotomy of the entire stomach makes necessary the addition of a drainage procedure. Vagotomy with drainage impairs the ability of the antrum to ‘mill’ food and to propel chyme onwards, and destroys or by-passes the pyloric sphincter. These surgical insults to normal gastric physiology harm the patient by producing dumping, diarrhoea, bilious vomiting, steatorrhoea, and gross elevation of serum gastrin. The main conclusion of this paper is that such harm can be avoided, because it is shown that even patients with pyloric stenosis can be treated by H.S.V. without a drainage procedure. The routine use of complete gastric vagotomy with a drainage procedure in the elective surgical treatment of duodenal ulcer is no longer justified.

Anterior highly selective vagotomy with posterior truncal vagotomy: a simple technique for denervating the parietal cell mass.

Abstract Anterior highly selective vagotomy with posterior truncal vagotomy was performed in a consecutive series of 20 patients with uncomplicated chronic duodenal ulcer. After identification of the vagal trunks the anterior leaf of the lesser omentum was separated from the lesser curve of the stomach, carefully preserving the anterior nerve of Latarjet. The distal extent of the dissection was from a point approximately 7–8 cm from the pylorus. After ensuring that all branches of the anterior nerve passing to the lesser curve had been severed, the trunk of the posterior nerve was divided and a segment removed. The lower 6–7 cm of oesophagus were cleared of nerve fibres. All the patients recovered well from the operation and none suffered from prolonged gastric stasis in the postoperative period. Fourteen patients are well and free of symptoms (follow-up 3–15 months). Four patients have a sense of epigastric fullness and one of these vomits occasionally. Three patients have been troubled periodically by diarrhoea and one has ulcer-type pain although no recurrence has been seen on endoscopy or on barium meal examination. One week after surgery the mean percentage reduction was 73 per cent in basal acid output and 65 per cent in peak acid output after stimulation with pentagastrin. Five of the patients had late positive insulin tests; 3 of these were the first 3 patients in the series. The other patients were insulin negative. In 10 patients the pattern of gastric emptying of a radionuclide-labelled meal 6 months after surgery was compared with that of 23 controls. The mean half-emptying time was similar in the two groups (71·7 ± 10·1 min v. 71·3 ± 3·8 min). It is concluded that this new and simpler operation is technically feasible and it may be worth a cautious trial in centres with a special interest in this type of surgery.

The surgical factors influencing duodenogastric reflux.

The surgical factors influencing duodenogastric reflux have been assessed in dog and man using the biliary radiopharmaceutical 99mTc-EHIDA. Cholecystectomy led to a significant increase in the amount of reflux (P less than 0.01), but the combination of truncal vagotomy and pyloroplasty in addition to cholecystectomy produced a greater amount of reflux (P less than 0.01). In man, cholecystectomy also resulted in a significant increase in the amount of reflux (P less than 0.01). In ten control subjects reflux occurred but the amount was small and was not significantly different from the modified highly selective vagotomy group (n = 20). Symptomatic patients after truncal vagotomy and pyloroplasty (n = 16) showed a significant increase in the amount of reflux (P less than 0.002) but the combination of vagotomy and pyloroplasty in addition to cholecystectomy (n = 15) demonstrated the greatest amount of reflux (P less than 0.002). Similarly the addition of cholecystectomy to highly selective vagotomy (n = 9) showed a significant increase in the amount of reflux (P less than 0.02). Reconstruction of the pylorus (n = 8) was not a satisfactory procedure for the prevention of reflux but antrectomy and Roux-en-Y biliary diversion (n = 8) resulted in a significant reduction in the amount of reflux (P less than 0.001) and this was associated with clinical improvement.

Motility changes in the antrum after proximal gastric vagotomy.

The normal pattern of resting and post-prandial motor activity in the gastric antrum has been established by observations in 6 dogs. There was a gradual increase in the amplitude of contraction during the first 2 hours after eating; this was maintained for 3 hours and then declined. For the first 45 minutes terminal antral contraction occurred, partially retaining and triturating the gastric contents. After 45 minutes the waves became sequential, symmetrical, increased in vigour and actively pumped food into the duodenum. Vagotomy modified the mechanism of the antrum in various ways. Truncal and selective vagotomy reduced the work capability to 20 per cent of its normal value when recorded 1 month after operation. In both groups the waves were disorganized. Proximal gastric vagotomy abolished the braking mechanism and removed the initial inhibitory stimuli to antral motility. Within 1 month of operation the antrum had regained 58 per cent of its normal work capability and the contractions were well organized.

Highly selective vagotomy or truncal vagotomy and pyloroplasty for chronic duodenal ulceration: A randomized, prospective clinical study

The results of a randomized, prospective clinical trial of highly selective vagotomy (HSV) versus truncal vagotomy and pyloroplasty (TVP) in 126 male patients undergoing elective surgery for chronic duodenal ulceration are presented. The operations were performed by surgeons of all grades of experience. At a mean follow-up time of just over 3 years a satisfactory result was obtained in 93 per cent of patients following HSV and 78 per cent of patients following TVP, the difference being probably statistically significant (P less than 0.05). The incidence of early and late dumping, bile vomiting, flatulence, post-prandial epigastric discomfort and wound infection was statistically significantly less after HSV than after TVP. Three patients have developed a recurrent duodenal ulcer after each type of operation (5.4 per cent). At this early stage HSV has advantages over TVP; it will be interesting to see if these are maintained with the passage of time.

Effect of antroneurolysis on gastric secretion in dogs with total gastric fistula.

Abstract The operation of antroneurolysis is performed by circumferential sharp dissection in the submucosal plane of the entire gastric antrum, which severs the vagal nerve-supply to the antral mucosa. It might thus be regarded as a conservative variant of antrectomy, the purpose of which is to diminish gastrin release without disturbing antral peristalsis or the mechanism of the pylorus. Its possible value as an adjunct to highly selective vagotomy in man is evaluated in this study in the dog. The antroneurolysed antrum was left in continuity with the remainder of the stomach whose vagal nerve-supply remained intact. Gastric secretion was collected via a cannula or fistula draining the whole stomach. Outputs of acid and pepsin in response to insulin, pentagastrin, meat extract, and acetylcholine were found to be undiminished after antroneurolysis. It is concluded that antroneurolysis has no place at present in clinical gastric surgery.

Long-term results of highly selective vagotomy: a prospective study with implications for future laparoscopic surgery.

Between 1979 and 1984, 141 patients (110 men, 31 women) underwent highly selective vagotomy (HSV) by a standard open technique for duodenal ulcer. All patients had received preoperative treatment with full-dose H2-receptor antagonists. Some 107 of these patients underwent HSV for persistent relapse on withdrawal of H2-receptor antagonists (relapsing responders) and 30 because of non-response to such drugs. After 4 years of follow-up, non-responders were found to be more likely to have symptoms after operation (P < 0.001), but did not have a higher rate of recurrent ulceration. At a median of 11 (range 8-14) years after operation 126 patients were still alive; 115 (91 per cent) of these were followed up. Ten patients (9 per cent) were found to have had endoscopically proven recurrence and eight (7 per cent) still had symptoms without evidence of recurrence. The endoscopic recurrence rate and symptom rate at 11 years were no longer significantly different between relapsing responders and non-responders. The preoperative response to H2-receptor antagonist therapy does not help in predicting the likelihood of ulcer recurrence or long-term symptoms after HSV. Post-operative symptoms do not necessarily predict long-term ulcer recurrence. The long-term endoscopic recurrence rate after HSV is low and, if equally good results can be obtained laparoscopically, this will be an important and cost-effective option in the management of duodenal ulcer.

Diarrhoea after vagotomy. A comparative study of truncal and bilateral selective vagotomy.

Diarrhoea after vagotomy. A comparative study of truncal and bilateral selective vagotomy.

The effect of vagotomy on the inhibition of gastric secretion by intraduodenal fat.

Abstract It has been suggested that the inhibition of gastric secretion by intraduodenal fat is a vagal phenomenon in man. Selective and highly selective vagotomy, by preserving this reflex, could offer advantages over truncal vagal section. This paper reports the effect of intraduodenal fat on pentagastrin-stimulated gastric secretion in duodenal ulcer patients before and after truncal vagotomy. Marked inhibition of gastric secretion occurred in all the patients. In the postoperative group gastric secretion was almost totally abolished following fat infusion despite the absence of an abdominal vagal supply. The results suggest that inhibition of gastric secretion by intraduodenal fat is mediated by a nonvagal mechanism in man; from this point of view, therefore, there is little advantage in attempting to preserve the nerve-supply to the duodenum at vagotomy.

The effect of highly selective vagotomy on the relationship between gastric mucosal blood flow and acid secretion in man.

Previous work has shown that the duodenal ulcer population can be defined by a lower ratio between gastric mucosal blood flow and acid secretion (during pentagastrin stimulation) than is found in normal subjects. The results of the present investigation have shown that the ratio is restored to normality by highly selective vagotomy. This suggests that increased tonic activity of the vagus on the parietal cell is one of the important disorders in duodenal ulceration.

Where is your vagotomy incomplete? Observations on operative technique.

There is a trend in gastric surgery towards more selective types of vagotomy but the techniques are more difficult and incomplete nerve section may be more likely. Using the Grassi intra-operative test of mucosal pH, we have studied 50 consecutive patients, 13 having truncal vagotomy, 9 having bilateral selective vagotomy and 28 having proximal gastric vagotomy. We have identified four distinct areas of the stomach where nerve fibres are likely to be left. Three of these can usually be eliminated by careful attention to technique, but the fourth--the distal extent of the parietalcell mass--can only be identified by a precise intra-operative test; this is relevant to proximal gastric vagotomy but not to truncal vagotomy. Unexpected anatomical variations of the vagus nerve branches were found in 8 patients. A precise intra-operative test of residual innervation is particularly helpful in establishing the technique of proximal gastric vagotomy.

Intrinsic factor secretion after vagotomy

The intrinsic factor (IF) output during basal and Histalog-stimulated gastric secretion has been estimated in two series of patients with chronic duodenal ulcer before and 3 months or more after treatment by either highly selective vagotomy or truncal vagotomy and pyloroplasty. The effects of the two different vagotomy operations appear to be virtually identical and each produced significant reductions in intrinsic factor secretion after Histalog stimulation. This confirms the view expressed by previous workers that it is the vagotomy as such which is responsible, excluding the drainage procedure from any possible role. Furthermore, as these results were demonstrated 3 months after operation, it is likely that the depressed IF secretion is a permanent feature and one which, it is postulated, may become progressively more severe. In both series there is a marked reduction in IFoutput during the second hour of stimulated gastric secretion, indicating an early wash-out of preformed IF. This persists after vagotomy.

The disappearing chief cell phenomenon (DCP): a preliminary report.

The appearance of chief cells was studied in normal dogs and in dogs after anterior and bilateral highly selective vagotomy. The normal chief cell is columnar in shape, with a well-defined cell membrane, basal nucleus and basophilic cytoplasm. Many cells show what has been called the 'disappearing chief cell phenomenon'--DCP. The features of the DCP are striking. There is fragmentation of the cell membrane, loss of cytoplasm, changes in the appearance of the nucleus and actual disappearance of some cells. The parietal cells remain normal. The DCP is seen in normal mucosa and should not be regarded as evidence of chronic gastritis. From this preliminary study it is suggested that the procedure of highly selective vagotomy may have a specific effect on pepsin secreting cells, increasing the amount of the DCP.

Clinical results of 229 patients with duodenal ulcer 1-6 years after highly selective vagotomy.

The aim of this study was to assess the clinical results after highly selective vagotomy (HSV) when used routinely at a district general hospital. A total of 229 patients with chronic duodenal or prepyloric ulcers was included in a 92 per cent complete follow-up 1-6 years after an elective HSV without drainage. There was no postoperative mortality, and the frequency of postoperative complicatons was low. Transient dysphagia and early fullness each occurred in about a quarter of the patients, whereas persistent dumping was found only in 1.3 per cent and diarrhea in 2.2 per cent of the patients. Recurrent ulcer was diagnosed in 12.7 per cent of the patients, but this figure decreased to 9.3 per cent after exclusion of one of the 24 surgeons involved. The overall clinical results according to the modified Visick classification were recorded as excellent or very good in 70 per cent and unsatisfactory in 20 per cent. The failures were almost exclusively due to a proved or suspected recurrence or to gastric retention, and further operations have been performed on 27 of these patients. After reoperation only 8 patients (3.5 per cent) remained failures according to the patient's own judgement at the time of follow-up. The recurrence ratein this study was considered disquietingly high with regard to the short observation time. However, other obvious advantages of the method and the possibility of improved results after adjustment of the surgical technique were considered to justify continued use of HSV as a routine procedure.

The effect of posture on the gastric emptying of solid meals in normal subjects and patients after vagotomy.

Abstract The effect of posture on gastric emptying of solid meals has been studied in normal subjects and compared with the effect in patients who had recently had either a truncal vagotomy and pyloroplasty or a highly selective vagotomy. The meal was labelled with 51Cr and emptying monitored with a gamma camera. The stomach of the normal subjects emptied at the same rate whether they were standing up or lying down. Patients tested less than 3 months aflev truncal vagotomy and pyloroplasty and also after highly selective vagotomy had significantly faster (P &amp;lt; 0.01) gastric emptying when standing than when lying down. Afrer trunral vagotomy and pyloroplasty emptying was significantly slower than normal when lying down but normal when standing. After highly selective vagotomy emptying was normal when lying down but significantly faster than normal when standing.

A prospective randomized trial of vagotomy in chronic duodenal ulceration

In a prospective, randomized trial, 76 patients with duodenal ulceration treated by truncal vagotomy and pyloroplasty were compared with 77 patients who underwent highly selective vagotomy. A total of 149 patients was followed up for from 1 to 4 years, the average follow-up period being 2.6 years. There was no operative mortality and no significant difference in postoperative morbidity between the two groups. The incidence of recurrent ulceration was greater after highly selective vagotomy, but this difference was not statistically significant. The clinical results were comparable in each group, and although the incidence of diarrhoea and dumping was greater after vagotomy and pyloroplasty, this difference was not statistically significant.