Truncal Vagotomy And Pyloroplasty Research Articles

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 pyloroplasty on gastric emptying: long term results as obtained with a labelled test meal 14-43 months after operation.

The mean gastric transit time (t) and the half-time of gastric emptying (t/2) of a labelled test meal have been studied in 18 patients more than 1 year after gastric surgery for peptic ulcer and compared with those in 18 healthy controls. Of the patients, 6 had undergone proximal gastric vagotomy alone (PGV), L had had proximal gastric vagotomy and pyloroplasty (PGVP) and in 6 truncal vagotomy and pyloroplasty (TVP) had been performed. The t and t/2 of patients with PGV alone did not differ significantly from the values of the control group. The t and t/2 in patients after PGVP and TVP, however, were significantly lower than in both controls and patients after PGV alone. There was no statistically significant difference between the groups with PGVP and TVP. The results of this study suggest that the lasting effects of vagotomy operations on gastric emptying are due to the drainage procedure rather than the vagotomy.

Comparison of highly selective vagotomy with truncal vagotomy and pyloroplasty: Results at 8–15 years

In 1983 we reported the early results (mean 5 years) of a prospective randomized comparison of highly selective vagotomy (HSV) with truncal vagotomy and pyloroplasty (TVP) where all 137 operations were performed by the same surgeon. HSV was significantly better than TVP in terms of Visick grading and side-effects. The same patients were assessed at a mean of 12 years (range 8-15 years) after operation. There was no difference on assessment using Visick grading between TVP (59 patients) and HSV (57 patients) (grades I and II, 75 per cent in each case). However, 20 per cent of TVP patients (but none of the HSV patients) had undergone reoperation in the intervening period. The endoscopically proven recurrence rate was 7 per cent after TVP and 5 per cent after HSV. This long-term follow-up supports the optimism that HSV is a better operation than TVP in the elective treatment of duodenal ulcer.

Endoscopic Obliteration for Bleeding Peptic Ulcer

A group of 133 patients treated for bleeding peptic ulcer in our Department, is reviewed. Within several hours of admission, all patients underwent upper gastrointestinal tract gastroscopy and obliteration of the bleeding ulcer. Bleeding gastric ulcers were found in 41 patients, and duodenal ulcers in 92 patients. Patients were classified according to the Forrest scale: IA – 11 patients, IB – 49 patients, IIA – 35 patients, lIB – 40 patients. In 126 (94.7%) patients the bleeding was stopped, and 7 required urgent surgery: 3 patients with gastric ulcer underwent gastrectomy, and 4 with duodenal ulcer – truncal vagotomy with pyloroplasty and had the bleeding site underpinned. Fifty-five patients underwent elective surgery: gastrectomy and vagotomy (18 patients with gastric ulcer), highly selective vagotomy (25 patients with duodenal ulcer) and truncal vagotomy and pyloroplasty (12 patients with duodenal ulcer). None of the patients was observed to have recurrent bleeding.

Effect of Vagotomy on Cholecystokinin Release and Gallbladder Contraction in Patients with Complicated Duodenal Ulcer

In this prospective study, we investigated gallbladder (GB) contraction and plasma cholecystokinin (CCK) levels in response to food intake before and 1 month after vagotomy in 27 patients with complicated duodenal ulcer. Highly selective vagotomy (HSV) was carried out in 6 patients, truncal vagotomy and pyloroplasty (TVP) in 4, truncal vagotomy and antrectomy (TVA) in 7, selective vagotomy and pyloroplasty (SVP) in 5 and selective vagotomy and antrectomy (SVA) in another 5 patients with pyloric stenosis. The results of our studies indicated that (1) basal plasma CCK levels increased significantly after vagotomy, (2) none of the vagotomy operations altered the integrated CCK response, (3) unlike HSV, SVA and TVA, SVP and TVP decreased GB emptying and (4) antrectomy significantly enhanced CCK release after food intake. We concluded from these findings that the operative procedure of HSV, SVA or TVA to circumvent bile stasis-related postvagotomy cholelithiasis is superior to SVP or TVP in the surgical treatment of complicated duodenal ulcer.

Gastric emptying after truncal vagotomy and pyloroplasty.

We have studied the gastric (fundic and antral) emptying of solids and liquids by a radionuclide method in 20 patients after truncal vagotomy and pyloroplasty (TVP) and in 10 control subjects. Gastric emptying of solids in TVP patients was similar to that of the control group (NS), but fundic emptying did not show a lag phase and was significantly faster. A significantly higher percentage of the solid fraction of the test meal filled the antrum (32 +/- 16% versus 20 +/- 9%; p less than 0.05), and this quantity was constant during the study period. Gastric emptying of liquids was greatly hastened after surgery. In 22 min 50 +/- 16% had left the stomach (versus 40 +/- 14% in controls; p less than 0.001). At 90 min the amount of liquid remaining in the stomach was similar to that in the control subjects. TVP accelerates fundic emptying of solids, which are transferred to an overfilled, paretic antrum. Liquids are emptied by a bimodal pattern with a precipitous initial emptying followed by a second slower phase.

Bleeding gastroduodenal ulcers: choice of operations.

AbstractManagement of upper gastrointestinal tract hemorrhage continues to present a challenge in surgical judgment. Endoscopy is the mainstay to precise diagnosis and, although some authorities feel that this modality has not reduced overall mortality, it has, however, played an important role in overall patient management. A bleeding patient may be classified into 1 of 3 separate categories and the algorithms outlined in this article are useful in selecting patients for nonoperative and operative treatment. For the good‐risk patient with a massively bleeding duodenal ulcer (DU) who is hemodynamically stable, truncal vagotomy‐antrectomy, Billroth I reconstruction is our procedure of choice if the inflammatory process in the duodenum is conducive to a safe resection. Our operative method is described along with variations in technique which are used when conventional end‐to‐end gastroduodenostomy is not feasible. Closure of the duodenal stump and Roux‐en‐Y reconstruction or placement of a Roux limb on a severely diseased duodenum following resection is employed in highly selected cases. The Billroth II type of reconstruction is rarely used today in our experience. Truncal vagotomy and pyloroplasty (TV‐P) is reserved for the high‐risk patient who is bleeding massively. An increasing number of these patients are currently encountered as transfers from our intensive care units with associated multiple organ disease and organ failures. Proximal gastric vagotomy with ulcer undersewing has limited application, in our judgment, when faced with the massively bleeding patient. Gastric resection with or without vagotomy along with ulcer excision is our choice for the massively bleeding gastric ulcer (GU) located in the distal 50–60% area of the stomach. For the high‐risk patient with GU, ulcer excision followed by TV‐P is indicated. For the rarely encountered giant GU, gastric resection may be the only option even though the patient is high risk.The choice of the proper operative procedure for the individual patient with massive gastric or duodenal hemorrhage should rest on the experience and the judgment of the surgeon.

The effect of varying levels of vagotomy on postprandial lower esophageal sphincter pressure and pancreatic polypeptide

AbstractFeeding produces a sustained increase in lower esophageal sphincter pressure (LESP) that is impeded by vagolytic blockade with atropine. This study determines the effect of varying levels of vagotomy on postprandial LESP and hormones known to stimulate LESP. Six dogs had measurement of fasting and postprandial LESP at 15‐min intervals after a 60 g beef meal. Blood was drawn for gastrin and pancreatic polypeptide (PP). The animals then had proximal gastric vagotomy (PGV) and subsequently, truncal vagotomy and pyloroplasty (TVP). The studies were repeated after recovery. Feeding produced a marked increase in LESP during the control period (p < 0.001) that was not affected by PGV (p > 0.6). In contrast, TVP completely abolished the LES response to feeding (difference from controls and PGV significant atp < 0.01). Gastrin response to feeding was accentuated by PGV, but this response normalized after TVP. Pancreatic polypeptide increased postprandially during the control period (p < 0.001). These increases were not affected by PGV (p > 0.6), but were completely abolished by TVP (difference:p < 0.001). Truncal vagotomy abolishes the postprandial rise in both LESP and pancreatic polypeptide. This suggests that vagal influences may play a role in the normal postprandial rise in LESP, possibly by release of pancreatic polypeptide, a hormone known to increase LESP.

POSTVAGOTOMY DIARRHOEA PUT INTO PERSPECTIVE

Truncal vagotomy and drainage is still the commonest operation for duodenal ulcer in the United Kingdom, despite its known association with diarrhoea. The frequency and severity of diarrhoea were compared in 102 randomly selected men 10 or more years after truncal vagotomy and pyloroplasty (TVP) and a control, group of 62 men taking long-term maintenance cimetidine treatment 2 or more years after healing of duodenal ulcer. 53% of the TVP group still had diarrhoea attacks compared with only 7% of the cimetidine group (p<0.001). Of the TVP patients, 11% had continuous diarrhoea and a further 22% at least one attack a week. 24% were displeased with the change in bowel function, and 8% complained that diarrhoea still seriously affected their lives. This side-effect is unacceptable and truncal vagotomy should now be avoided whenever possible.

Recurrence after duodenal ulcer surgery

The ulcer recurrence rate associated with the more conservative of two surgical procedures for chronic duodenal ulcers—highly selective vagotomy (HSV)— may be higher than that for the more radical procedure—truncal vagotomy and pyloroplasty (TVP). TVP was the most commonly performed surgery for chronic duodenal ulceration in Britain when a comparison trial began there in the early 1970s (<i>Br J Surg</i>1979;66:145-148). The procedure eliminates gastric acid hypersecretion by interrupting the triggering parasympathetic nerve network to the stomach, liver, gallbladder, bile ducts, pancreas, small intestine, and part of the large intestine. The pyloroplasty relieves gastric stasis. HSV involves selective dissection of the nerves to the fundus and body of the stomach, while preserving as many as possible of the vagal nerves to the antrum and pylorus. One investigator, James C. Thompson, MD, of the University of Texas Medical Branch, Galveston, recently noted that this operation "is associated with a rate of

Gastritis duodenitis, and circulating levels of gastrin in duodenal ulcer before and after vagotomy.

Biopsy specimens have been taken from five standard sites in the stomach and from the duodenal bulb in order to investigate the association of gastritis and duodenitis with duodenal ulcer. Twenty patients with chronic duodenal ulcer were investigated in this manner and in addition had gastric secretion tests and a radio-immune assay of serum gastrin under differing conditions. The patients were then treated either by a truncal vagotomy and pyloroplasty (TVP) or by a highly selective vagotomy without a drainage procedure (HSV). All the investigations were repeated three months postoperatively. Duodenal ulcer was usually associated with gastriitis, although this varied in extent and severity from patient to patient. In nearly all the patients, gastritis was present at the pyloric end of the stomach and along the lesser curve. In more than half of the patients, gastritis was also present in the body of the stomach but the fundus was usually spared. Chronic duodenitis was found in the duodenal bulb in all these patients. After vagotomy there was a marked increase in both the extent and severity of the proximal gastritis in both treatment groups but the distal gastritis remain almost unchanged. There was little change in the incidence of duodenitis after vagotomy but its severity was lessened. No correlation was found between the peak acid output (PAO) in response to Histalog and the severity of the gastritis or the duodenitis either before or after operation, with one exception. The postoperative PAO was significantly less in those patients who developed a severe proximal gastritis after vagotomy. No relationship was found between the severity of the distal gastritis and the levels of serum gastrin. No correlation was found between either the basal or peak acid output and the corresponding serum gastrin levels before or after vagotomy.

Psychiatric disturbance and post- vagatomy diarrhoea

Truncal vagotomy and drainage is still the commonest operation for duodenal ulcer in the United Kingdom, despite its known association with diarrhoea. The frequency and severity of diarrhoea were compared in 102 randomly selected men 10 or more years after truncal vagotomy and pyloroplasty (TVP) and a control, group of 62 men taking long-term maintenance cimetidine treatment 2 or more years after healing of duodenal ulcer. 53% of the TVP group still had diarrhoea attacks compared with only 7% of the cimetidine group (p<0.001). Of the TVP patients, 11% had continuous diarrhoea and a further 22% at least one attack a week. 24% were displeased with the change in bowel function, and 8% complained that diarrhoea still seriously affected their lives. This side-effect is unacceptable and truncal vagotomy should now be avoided whenever possible.