La Vagotomía Altamente Selectiva es aún un adecuado tratamiento para la úlcera péptica duodenal / Highly Selective Vagotomy is still a suitable treatment for duodenal peptic ulcer

RESUMEN Introducción: El tratamiento de la úlcera péptica duodenal (UPD) ha cambiado radicalmente en el transcurso de los últimos 50 años debido a la efectividad del tratamiento médico. Sin embargo, la cirugía todavía tiene un importante papel en el tratamiento de la úlcera duodenal; y dentro de éste la vagotomía. Objetivo: Describir el origen y evolución de la vagotomía altamente selectiva (VAS), y su papel en el tratamiento quirúrgico de la UPD. Material y métodos: Se revisó la bibliografía publicada durante los últimos 50 años relacionada con la VAS en el tratamiento quirúrgico de la UPD. La fuente de los datos utilizados fue obtenida de Clinical Key, Pubmed, Google, Scopus y Scielo, desde 1970 hasta 2020. Desarrollo: La VAS se aplicó por primera vez en el humano en 1967 por Holle y Hart. Posteriormente, Johnston y Wilkinson y Amdrup y Jensen en 1970, informan sus resultados, conservando el píloro. La única debilidad que se le atribuye a la VAS es una alta tasa de recurrencia de la úlcera; sin embargo, su mortalidad y morbilidad son mínimas, por lo que es la intervención de elección para la úlcera duodenal intratable o complicada. Conclusiones: Debido a la disminución en la necesidad del tratamiento quirúrgico, pocos cirujanos están entrenados y experimentados en esta operación técnicamente difícil; lo que ha sido el principal factor para las altas tasas de recurrencia. Sin embargo, consideramos que la VAS tiene vigencia actual en manos de cirujanos entrenados y experimentados.

ABSTRACT Introduction: The treatment of duodenal peptic ulcer (DPU) has radically changed over the last 50 years due to success of medical treatment. However, surgery still has an important role in the treatment of duodenal ulcer; and with this, vagotomy. Objective: To describe the origin and evolution of highly selective vagotomy (HSV), as well as its role in the surgical treatment of DPU. Material and Methods: We reviewed the bibliography published during the last 50 years in relation to highly selective vagotomy (HSV). The data used were obtained from the search carried out in Clincal Key, Pumed, Google, Scopus and Scielo databases during the period 1970-2020. Development: Highly Selective Vagotomy was first performed in humans by Holle and Hart in 1967. Later, their results were informed by Johnston and Wilkinson and Amdrup and Jensen in 1970, preserving the pylorus. The only weakness attributed to HSV is a higher ulcer recurrence rate; however, mortality and morbidity are minimal, so it is the intervention of choice for intractable or complicated duodenal ulcers. Conclusions: Because of the decline in the need for surgical management, fewer surgeons are trained and and have enough experince to perform this technically challenging surgery, which has been the main factor associated with higher recurrence rates. However, we consider that HSV has a current relevance when it is performed by trained and experienced surgeons.

Structural bases of gastrointestinal motility changes in parkinson's disease: study in rats / Bases estruturais das alterações da motilidade gastrintestinal na doença de parkinson: estudo em ratos

ABSTRACT Background: Gastrointestinal disorders are frequently reported in patients with Parkinson's disease whose disorders reduce the absorption of nutrients and drugs, worsening the clinical condition of patients. However, the mechanisms involved in modifying gastrointestinal pathophysiology have not yet been fully explained. Aim: To evaluate its effects on gastrointestinal motility and the involvement of the vagal and splanchnic pathways. Methods: Male Wistar rats (250-300 g, n = 84) were used and divided into two groups. Group I (6-OHDA) received an intrastriatal injection of 6-hydroxydopamine (21 µg/animal). Group II (control) received a saline solution (NaCl, 0.9%) under the same conditions. The study of gastric emptying, intestinal transit, gastric compliance and operations (vagotomy and splanchnotomy) were performed 14 days after inducing neurodegeneration. Test meal (phenol red 5% glucose) was used to assess the rate of gastric emptying and intestinal transit. Results: Parkinson's disease delayed gastric emptying and intestinal transit at all time periods studied; however, changes in gastric compliance were not observed. The delay in gastric emptying was reversed by pretreatment with vagotomy and splanchnotomy+celiac gangliectomy, thus suggesting the involvement of such pathways in the observed motor disorders. Conclusion: Parkinson's disease compromises gastric emptying, as well as intestinal transit, but does not alter gastric compliance. The delay in gastric emptying was reversed by truncal vagotomy, splanchnotomy and celiac ganglionectomy, suggesting the involvement of such pathways in delaying gastric emptying.

RESUMO Racional: Distúrbios gastrintestinais são frequentemente relatados em pacientes com doença de Parkinson cujos distúrbios reduzem a absorção de nutrientes e fármacos, agravando o quadro clínico dos pacientes. No entanto, os mecanismos envolvidos na alteração da fisiopatologia gastrintestinal ainda não foram totalmente elucidados. Objetivo: Avaliar os seus efeitos sobre a motilidade gastrintestinal e o envolvimento das vias vagal e esplâncnica. Métodos: Ratos Wistar machos (250-300 g, n=84) foram utilizados e divididos em dois grupos. O grupo I (6-OHDA) recebeu injeção intraestriatal de 6-hidroxidopamina (21 µg/animal). O grupo II (controle) recebeu solução salina (NaCl, 0,9%) nas mesmas condições. O estudo do esvaziamento gástrico, trânsito intestinal, complacência gástrica e operações (vagotomia e esplancnotomia) foram realizadas 14 dias após a indução da neurodegeneração. Refeição teste (vermelho de fenol+glicose 5%) foi utilizada para avaliar a taxa de esvaziamento gástrico e o trânsito intestinal. Resultados: A doença de Parkinson retardou o esvaziamento gástrico e o trânsito intestinal em todos os tempos estudados; porém, alterações da complacência gástrica não foram observadas. O retardo do esvaziamento gástrico foi revertido por pré-tratamento com vagotomia e esplancnotomia+gangliectomia celíaca, sugerindo assim, o envolvimento de tais vias nos distúrbios motores observados. Conclusão: A doença de Parkinson compromete o esvaziamento gástrico, bem como o trânsito intestinal, mas não altera a complacência gástrica. O retardo do esvaziamento gástrico foi revertido pela vagotomia troncular, esplancnotomia e gangliectomia celíaca, sugerindo o envolvimento de tais vias no retardo do esvaziamento gástrico.

Effect of bilateral cervical vagotomy on microglial activation in spinal cord in a rat model of persistent postoperative pain / 中国医师杂志

Objective To investigate the effect of bilateral cervical vagotomy on microglial activation in spinal cord in a rat model of persistent postoperative pain evoked by skin/muscle incision and retraction (SMIR).Methods Thirty six male Sprague-Dawley rats were randomly divided into three groups (n =12 each group):group sham operation,group SMIR,and group SMIR + bilateral cervical vagotomy (SV).The rat model of persistent postoperative pain evoked by SMIR was established according to the method described by Flatter.Pain behavior was assessed by paw mechanical withdrawalthreshold (MWT) to yon Frey filament stimulation at 1,3,and 5 days after operation.Four animals were sacrificed at each time point in each group to detect the expression of Iba-I (a specific marker of microglia) in the spinal dorsal horn with immunofluorescence and the microglia was counted.Results MWT was significantly decreased atT1-5 in SMIR and SV (10.3 ±0.6,9.7 ±0.8,9.6 ±0.5; 8.0 ±0.7,7.7 ±0.4,7.6 ± 0.3),while the expression of Iba-1 and microglia counts in the spinal dorsal horn were significantly in-creased at T1-5 in SMIR and SV (1428 ± 134,1245 ± 129,and 1001 ± 117 ;8.0 ± 0.7,7.7 ± 0.4,and 7.6 ±0.3; 187 ± 13,164 ± 11,and 142 ± 14;and 241 ±21,230 ±21,and 202 ± 19).In group SV as compared to group SMIR,MWT was significantly decreased at T1-5,while the expression of Iba-1 and microglia counts in the spinal dorsal horn were significantly increased at T1-5.Conclusions Vagus nerve plays an important role in microglial activation in spinal cord in a rat model of persistent postoperative pain evoked by skin/muscle incision and retraction.

Vagus nerve preserving pericardial devascularization with subtotal splenectomy for the treatment of portal hypertension / 中华普通外科杂志

Objective To investigate the clinical effect of vagus nerve preserving pericardial devascularization plus subtotal splenectomy in treating portal hypertension with a history of variceal bleeding.Methods The clinical data of 33 cases of portal hypertension with variceal hemorrhage treated with vagus nerve preserving selective pericardial devascularization plus subtotal splenectomy from April 2004 to December 2013 (study group) were compared with that of 34 cases treated with pericardial devascularization plus splenectomy (control group).Results There was no mortality in two groups.The postoperative gastric drainage during the first 72 h were(1 525 ±30) ml in the study group and (2 130 ±40) ml in control group(P ＜0.05).Portal vein thrombosis developed in one case in the study group and 15 cases in the control group(P ＜ 0.05).Postoperative 3-year recurrent gastroesophageal varices hemorrhage was 15％ in the study group and 25％ in the control group (P ＜ 0.05).Postoperative 5-year variceal hemorrhage recurrence rate were 28％ in the study group and 30％ in the control group (P ＞ 0.05).Conclusions Maitaining vagus nerve selective pericardial devascularization plus subtotal splenectomy is of less postoperative complication and lower portal vein thrombosis rate and better patients' survival compared with pericardial devascularizatim plus total splenectomy.

Laparoscopic Truncal Vagotomy and Gatrojejunostomy for Pyloric Stenosis

PURPOSE: Peptic ulcer disease (PUD) remains one of the most prevalent gastrointestinal diseases and an important target for surgical treatment. Laparoscopy applies to most surgical procedures; however its use in elective peptic ulcer surgery, particularly in cases of pyloric stenosis, has not been popular. The aim of this study was to describe the role of laparoscopic surgery and an easily performed procedure for pyloric stenosis. We accordingly performed laparoscopic truncal vagotomy with gastrojejunostomy in 10 consecutive patients with pyloric stenosis. METHODS: Data were collected prospectively from all patients who underwent laparoscopic truncal vagotomy with gastrojejunostomy from August 2009 to May 2014 and reviewed retrospectively. RESULTS: A total of 10 patients underwent laparoscopic trucal vagotomy with gastrojejunostomy for peptic ulcer obstruction from August 2009 to May 2014 in oo university hospital. The mean age was 62.6 (+/-16.4) years old and mean BMI was 19.3 (+/-2.5) kg/m2. There were no conversions to open surgery and no occurrence of intra-operative complications. The mean operation time was 107 (90~130) minutes and blood loss was < 20 ml. Oral feeding was permitted for most patients on day 3 post operatively after upper gastrointestinal series to confirm no leakage or passage disturbance. The mean hospital stay was 7.3 days, the mean follow up duration was 19.8 (+/-17.2) months, and there was no mortality related to the operation. CONCLUSION: Laparoscopic truncal vagotomy and gastrojejunostomy was a good, easily performed surgical choice for patients with duodenal ulcer stricture.

Study of anatomical variations of anterior nerve of Latarjet and its clinical significance - A cadaveric study.

Background: Highly selective or proximal gastric vagotomy is one of the definitive treatment for gastric ulcers. The results of this operation in comparison to truncal vagotomy is well appreciated by the surgeons. On the contrary incomplete and inadequate performance of this procedure results in recurrence of ulcer, post vagotomy diarrhoea and dumping syndrome. Knowledge about the normal and abnormal patterns of the anterior and posterior gastric nerves is imperative to the surgeons performing highly selective vagotomy. Most studies of this region have been performed on western population and the perspective of truncal and highly selective vagotomy is based on western literature only. However Indian studies regarding this one, are only few and far in-between. Aims & Objective: To study the variations of anterior of Latarjet & its implication in surgical treatment of peptic ulcer. Materials and Methods: This nature of study on Indian population in this part of the country is an initiative. 55 stomach specimens were utilized for the study. The present study was divided in to 3 parts: (i) Cadaveric specimens – 12 in numbers; (ii) Autopsy specimens – 40 in numbers; and (iii) Foetal Specimens – 3 in number. The anterior gastric nerve was dissected out from the level of commencement to the level of termination by dissection method. The branching pattern, plexus formation and crow’s foot appearance at the level of termination of anterior gastric nerve were studied. Results of present study were statically analyzed & compared with the findings of previous research workers. Results: The study of pattern of the anterior nerve of Latarjet in the present study showed wide variations in terms of branching pattern, plexus formation and crow’s foot appearance. Conclusion: The discussion emphasises the most important anatomical details relevant to the achievement of adequate highly selective vagotomy. Knowledge of these variations is of great importance for the surgeons performing highly selective vagotomy to achieve better results.

Alterations of the gastric stump and not resected stomach mucosa after truncal vagotomy in rats

To evaluate morphological changes of the gastric stump and not resected stomach mucosa after the completion of truncal vagotomy. METHODS: Eighty male Wistar rats were divided into four groups: CT, TV, RY and RYTV. In CT group, abdominal viscera were manipulated and the abdominal cavity was closed, in TV vagal trunks were isolated and sectioned, in RY a partial Roux-en-Y gastrectomy was performed and in RYTV the vagal trunks were sectioned and a partial Roux-en-Y gastrectomy was performed. At the 54th week after surgery, the rats were euthanized. The findings were submitted to histological analyses. RESULTS: None macroscopic or histological alterations in groups TV and CT was observed. Specimens from RY and RYTV groups did not show alterations in the gastric stump mucosa. At the jejunal side of the gastroenterostomy we found shallow ulcerative lesions always single, well-defined and with variable diameter 3 to 6 mm, six times in the RY group and none in the RYTV group (RY>RYTV, p=0.008). Neoplastic or preneoplastic lesions were not diagnosed in all groups. CONCLUSION: Truncal vagotomy is a safe and non-carcinogenic method in not resected and partially resected stomach.

Comparison of clinical effects between laparoscopic Nissen fundoplication combined with highly selective vagotomy and traditional laparoscopic Nissen fundoplication in treatment of gastroesophageal reflux disease / 吉林大学学报(医学版)

Objective To compare the clinical effects of laparoscopic Nissen fundoplication (LNF)combined with highly selective vagotomy(HSV)(LNFHSV)in treatment of gastroesophageal reflux disease(GERD),and to provide reference for the clinical application of LNFHSV.Methods 22 patients with a history of GERD unrelieved by medication and underwent LNFHSV were selected.At the same time ,36 patients with GERD underwent LNF were used as control.The mean operation time,hospital stay,incidence of main operative complications,HSS complete remission and Demeester scores of the patients in two groups were retrospectively analyzed.Results The Demeester scores,hospital stay, incidence of main operative complications of the patients in two groups before operation had no significant differences(P>0.05).The mean operation time in LNFHSV group (90 min±35 min) was longer than that in LNF group(65 min± 21 min).The Demeester scores of the patients in two groups after operation had significant difference(P<0.05).The HSS complete remission rate of the patients in LNFHSV group was 91.1%,the part remission rate was 8.9%,and no effectiveness was 0;they were 83.3%,13.8%,and 2.8% in LNF group;there were significant differences between two groups(P<0.05).Conclusion LNFHSV has better effectiveness in controlling GERD than LNF procedure.

Intragastric gavage with denatonium benzoate acutely induces neuronal activation in the solitary tract nucleus via the vagal afferent pathway

Natural toxic substances have a bitter taste and their ingestion sends signals to the brain leading to aversive oral sensations. In the present study, we investigated chronological changes in c-Fos immunoreactivity in the nucleus tractus solitarius (NTS) to study the bitter taste reaction time of neurons in the NTS. Equal volumes (0.5 mL) of denatonium benzoate (DB), a bitter tastant, or its vehicle (distilled water) were administered to rats intragastrically. The rats were sacrificed at 0, 0.5, 1, 2, 4, 8, or 16 h after treatment. In the vehicle-treated group, the number of c-Fos-positive nuclei started to increase 0.5 h after treatment and peaked 2 h after gavage. In contrast, the number of c-Fos-positive nuclei in the DB-treated group significantly increased 1 h after gavage. Thereafter, the number of c-Fos immunoreactive nuclei decreased over time. The number of c-Fos immunoreactive nuclei in the NTS was also increased in a dose-dependent manner 1 h after gavage. Subdiaphragmatic vagotomy significantly decreased DB-induced neuronal activation in the NTS. These results suggest that intragastric DB increases neuronal c-Fos expression in the NTS 1 h after gavage and this effect is mediated by vagal afferent fibers.

Evaluación posoperatoria de los pacientes con úlcera perforada / Postoperative evaluation of patients operated on perforated gastro-duodenal ulcer

Introducción: la úlcera péptica gastroduodenal constituye después de la hemorragia la complicación ulcerosa más frecuente y la más grave de todas. Ocurre entre el 2 y 5 porciento de los pacientes con enfermedad ulcerosa y sus síntomas son provocados por la acción del jugo gástrico derramado en la cavidad abdominal. Objetivo: valorar la evolución de los pacientes operados de urgencia con el diagnóstico de úlcera gastroduodenal perforada. Métodos: se realizó un estudio observacional descriptivo con carácter prospectivo en el periodo comprendido entre enero del 2005 y diciembre del 2011. El universo estuvo constituido por todos los pacientes intervenidos quirúrgicamente por úlcera gastroduodenal perforada en el servicio de Cirugía General del Hospital General Docente Enrique Cabrera durante ese período. Los datos fueron transferidos a una planilla de recolección de datos que posteriormente fue procesada y analizada en el Microsoft Office Excel 2007. Los resultados se expresaron en tablas y gráficos, y solo se usaron técnicas de estadística descriptiva; distribuciones de frecuencia absolutas y relativas para las variables cuantitativas y media aritmética para las cuantitativas. Resultados: el grupo de edad predominante fue de mayores de 60 años con 42,4 porciento. El sexo masculino fue el de mayor incidencia con un 88 porciento. La asociación tabaco más café y solo tabaco constituyeron los hábitos tóxicos más frecuentes con 23,1 porciento cada uno. El dolor abdominal estuvo presente en el 100 porciento de los pacientes. La radiografía de tórax con el paciente de pie fue el estudio complementario más utilizado para corroborar la sospecha diagnóstica. En el 77 porciento de los pacientes se evidenció el neumoperitoneo radiológico. La úlcera duodenal fue la localización más frecuente (19 pacientes). En 15 pacientes (57,7 por ciento) se realizó la sutura y epiploplastia como tratamiento de urgencia. La complicación postoperatoria más frecuente fue la dehiscencia de la herida quirúrgica. Un paciente falleció en el postoperatorio con diagnóstico de bronconeumonía. Conclusiones: los pacientes mayores de 60 años de edad y del sexo masculino constituyeron el mayor número con el diagnóstico de úlcera gastroduodenal perforada. La localización más frecuente de la úlcera fue en el duodeno. La sutura y epiploplastia fue el proceder más utilizado como tratamiento. La dehiscencia de la sutura fue la complicación que más se observó en la serie(AU)

Introduction: Perforated peptic gastroduodenal ulcer represents the most frequent and serious complication after hemorrhage. It occurred in 2 to 5 percent of patients diagnosed as peptic ulcer and the main symptoms are caused by the gastroduodenal content spilled over the peritoneal cavity. Objective: To assess the recovery of patients operated on from perforated gastroduodenal ulcer at emergency setting. Methods: Prospective, observational and descriptive study carried out from January 2005 through December 2011. The universe of study was all the patients operated on from perforated gastroduodenal ulcer in Enrique Cabrera general teaching hospital's general surgery service in this period. Data were collected in forms, which were processed and analyzed by using Microsoft Office Excel 2007. The results were provided in tables and graphs; summary statistics, absolute and relative distribution for quantitative variables and arithmetic median for the quantitative ones were the statistical techniques used. Results: Men over 60 years old were the main group of patients with this pathology( 42.2 percent). The highest incidence rate was found in males (88 percent).Toxic habits like coffee plus cigar, and coffee alone were the most frequent, accounting for 23.1 percent each. All the patients complained of acute epigastric pain. Chest Rx on standing position was the most used study to confirm the suspected diagnosis. Radiological pneumoperitoneum was evident in 77 percent of patients. Duodenal ulcer was the main location of perforation (19 patients). Suture and epiploplasty were performed as emergency treatment in 15 patients (57.7 percent). Surgical wound dehiscence was the most common complication. One patient died from bronchopneumonia during the postoperative phase. Conclusions: Patients aged over 60 and males represented the highest number with diagnosis of perforated gastroduodenal ulcer. The most frequent location was duodenum. Epipoplasty and suture were the main therapeutic methods. Suture dehiscence was the most observed complication in this group(AU)

Biliopancreatic diversion with duodenojejunal exclusion associated with truncal vagotomy: a new proposal for type 2 diabetes mellitus treatment / Derivação biliopancreática com exclusão duodeno-jejunal associada à vagotomia troncular: uma nova proposta para o tratamento do diabetes melito tipo 2

PURPOSE: To evaluate the effectiveness of the biliopancreatic diversion surgery with duodenojejunal exclusion in combination with truncal vagotomy in type 2 diabetes mellitus (T2DM) patients with overweight or class I or II obesity. METHODS: The study included ten patients with T2DM and class I or II obesity or overweight who were subjected to biliopancreatic diversion with duodenojejunal exclusion in combination with truncal vagotomy. The blood glucose levels during the pre- and postoperative periods were compared using the Friedman test. The significance level adopted was 5%. RESULTS: There were significant differences between preoperative and postoperative blood glucose levels at three months (p=0.01), six months (p=0.001) and 12 months (p=0.001). There was also a significant difference between one month postoperative blood glucose and six months postoperative blood glucose (p=0.01). Glycosylated hemoglobin levels decreased in 80% of patients, there was marked improvement in their lipid profiles, and the average BMI reduction was 7.0±1.5 kg/m² at 12 months after the surgery. CONCLUSION: In patients with type 2 diabetes mellitus associated with class I/II obesity or overweight, performing biliopancreatic diversion with duodenojejunal exclusion in combination with truncal vagotomy resulted in glycemic control, reduction of excess weight, and improvement of lipid profile 12 months after the surgery.

OBJETIVO: Avaliar a eficácia da operação de derivação biliopancreática com exclusão duodeno-jejunal associada com vagotomia troncular em doentes com diabetes tipo 2 com sobrepeso ou obesidade classe I ou II. MÉTODOS: Foram estudados dez doentes com diabetes melito tipo 2 e sobrepeso ou obesidade grau I ou II submetidos à derivação biliopancreática com exclusão duodeno-jejunal associada à vagotomia troncular. Os valores de glicemia no pré e no pós-operatório foram comparados pelo teste de Friedman. O nível de significância adotado foi de 5%. RESULTADOS: Houve diferença significante (p=0,01) nas glicemias pré e pós-operatórias de três meses, de seis meses (p=0,001) e de 12 meses (p=0,001). Houve diferença significante entre a glicemia pós-operatória de um mês e glicemia pós-operatória de seis meses (p=0,01). O nível de hemoglobina glicosilada reduziu-se em 80% dos doentes, houve melhora acentuada do perfil lipídico e a média da redução do IMC foi de 7,0±1,5 kg/m² após 12 meses da operação. CONCLUSÃO: No paciente com diabetes melito tipo 2 associado com sobrepeso ou obesidade grau I/II, a realização da derivação biliopancreática com exclusão duodeno-jejunal associada à vagotomia troncular proporcionou controle glicêmico, redução do excesso de peso e melhora do perfil lipídico após 12 meses da operação.

Evolução histórica da úlcera péptica: da etiologia ao tratamento / History of peptic ulcer: from etiology to treatment

Objetivos: revisar os principais aspectos históricos da progressão do conhecimento sobre a etiologia da úlcera péptica e das terapêuticas clínicas e cirúrgicas empregadas no tratamento desta enfermidade.Fonte de dados: revisão bibliográfica através do PubMed. Foram analisados artigos selecionados sobre a história da úlcera péptica.Síntese dos dados: durante décadas, cirurgiões acreditaram que a doença da úlcera péptica era causada pelo excesso de ácido. O aforisma ?sem ácido, sem úlcera? foi enraizado em todos os residentes de cirurgia, e todos os esforços foram concentrados em eliminar o ácido através de uma operação. Com o advento da terapêutica farmacológica, houve melhora no sucesso do tratamento clínico e o número de casos cirúrgicos diminuiu. Com a descoberta do Helicobacter pylori, ainda mais pacientes foram tratados clinicamente e o número de casos cirúrgicos diminuiu novamente, persistindo apenas para casos refratários, hemorragia ou perfuração.Conclusões: úlcera péptica é uma doença reconhecida desde a antiguidade. A compreensão da evolução gradual das várias formas de seu tratamento serve de alerta e ensinamento de como evolui o conhecimento científico, onde as certezas efinitivas podem ser alteradas por inovações e resultados de pesquisas metodologicamente bem delineadas e realizadas, bem como elucidar a difícil trajetória que tem sido percorrida para poder solucionar o sofrimento dos pacientes que possuem essa enfermidade.

Aims: To review the main aspects of the historical progression of knowledge about the etiology of peptic ulcer and the clinical and surgical treatment used in the treatment of this disease.Source of data: A search was carried out at PubMed. Selected papers about the history of the peptic ulcer were reviewed.Summary of findings: For decades, surgeons were taught and believed that peptic ulcer disease was caused by acid.The dictum ?no acid, no ulcer? was engrained into every resident of surgery, and all efforts were focused on eliminating acid through operation. With the advent of pharmacological therapy, more ulcers were successfully treated medically and the number of surgical cases decreased. With the discovery of Helicobacter pylori, even more patients were successfully treated medically and the number of surgical cases decreased again, usually only to include refractory cases, hemorrhage or perforation.Conclusions: Peptic ulcer is a disease recognized since ancient times. The understanding of the gradual evolution of several forms of treatment serves as a warning and teaching of how scientific knowledge evolves, where the final certainties can be changed by innovations and research findings methodologically well designed and executed, and to clarify the difficult path that has been traversed in order to solve the suffering of patients who have this disease.

Tratamiento laparoscópico de la úlcera péptica duodenal: resultados a mediano y largo plazos / Laparoscopic treatment of peptic duodenal ulcer: long-term results

Aunque en la actualidad la cirugía electiva de la úlcera péptica duodenal se realiza con menos frecuencia, las indicaciones para el tratamiento quirúrgico continúan siendo las mismas y existe un pequeño número de pacientes que aún debe ser operado. Las modalidades de vagotomías laparoscópicas más aceptadas han sido las de Taylor (vagotomía troncular posterior y seromiotomía gástrica anterior) y de Hill-Barker (vagotomía troncular posterior y vagotomía altamente selectiva anterior), debido a su eficacia, seguridad y simplicidad. El objetivo de este estudio es evaluar los resultados a mediano y largo plazos de estas técnicas laparoscópicas. Entre 1994 y 2001, fueron realizadas en el Centro Nacional de Cirugía de Mínimo Acceso 183 vagotomías laparoscópicas (108 vagotomías de Hill-Barker y 75 vagotomías de Taylor). Los pacientes fueron seguidos prospectivamente para evaluar mediante variables como: tiempo quirúrgico, mortalidad, morbilidad, efectos colaterales de la operación y recurrencia de la enfermedad; la practicabilidad de los procedimientos, su seguridad y los resultados funcionales a largo plazo. El tiempo quirúrgico promedio fue 116,3 minutos para la técnica de Hill-Barker, y 149,2 minutos para la técnica de Taylor. No hubo conversión a cirugía convencional y la mortalidad perioperatoria fue nula. La estancia hospitalaria promedio fue 2,1 días. Las principales complicaciones postoperatorias fueron: diarrea (10,9%) y retardo del vaciamiento gástrico (4,4%). El índice global de recidiva fue de 10,4%. Las vagotomías laparoscópicas constituyen la opción de tratamiento ideal para la úlcera péptica duodenal, cuando el tratamiento quirúrgico está indicado, debido a bajos índices de mortalidad, recurrencia y trastornos funcionales colaterales a largo plazo, a lo cual se añaden las ventajas de la cirugía mínimamente invasiva.

Although elective surgery for duodenal ulcer is less frequent today, the indications for surgical treatment remain the same and there is still a small proportion of patients who should be considered for surgical treatment. The Taylor's procedure (posterior truncal vagotomy with anterior gastric seromiotomy) and the Hill-Barker's procedure (posterior truncal vagotomy with anterior highly selective vagotomy) have been the most accepted modalities of vagotomies when they have been performed by laparoscopy because of their efficacy, safety and simplicity. The objective of this study was to evaluate the long-term results of these laparoscopic techniques. 183 consecutive patients receiving either Taylor (n=75) or Hill-Barker (n=103) procedures at National Center for Minimal Access Surgery between 1994 and 2001, were prospectively followed for 1 to 80 (mean, 52) month to assess their outcomes. Factors related to feasibility, safety and long-term functional result, like operative time, mortality, morbidity, side effects of operation and recurrence, were analyzed during the follow-up. The mean operative time was 116,3 minutes for Hill-Barker's procedure and 149,2 minutes for Taylor's procedure. Our results show no operative mortality and no conversion to an open procedure. Hospital stay was 2,1 days. Diarrhoea (10,9%) and delayed gastric emptying (4,4%) were the most frequent complications. The global rate of recurrent ulceration was 10,4%. The low rates of mortality, recurrence and functional disorders at long-term, added to the advantages of minimal invasive surgery confers to laparoscopic vagotomies the condition of ideal treatment for duodenal ulcer, when surgical treatment is indicated.

Assessment of vagotomy status with postprandial urinary alkaline tide.

Aim: This study was carried out to assess whether the postprandial urinary alkaline tide, as a marker for the completeness of vagotomy, is dependent on the nature of the test meal, whether it is affected by proton pump inhibitor therapy, and whether it is reliable. Methods: The postprandial urinary alkaline tide (PUAT) pattern was prospectively assessed in three different study groups and one control group of healthy volunteers. The three study groups were as follows; A (n = 20) i.e. the Proton Pump Inhibitor (PPI) Group; B (n = 25) i.e. the Truncal Vagotomy (TV) Group; and C (n = 5) i.e. the Recurrent Ulcer (RU) Group. Urinary pH was measured by a pocket digital pH meter. Results: Postprandial urinary alkaline tide in the control group was significantly higher compared to the fasting levels. Liquid diet did not elicit a significant urinary alkaline tide response. There was a statistically significant fall in both fasting urinary pH (5.34 ± 0.70 vs. 4.80 ± 0.61, p = 0.031) and the postprandial alkaline tide (6.99 ± 0.79 vs. 4.94 ± 0.63, p = 0.0001) after taking proton pump inhibitors. In the truncal vagotomy and gastrojejunostomy group it was found that there was a significant fall in both the mean fasting (5.28 ± 0.58, vs. 4.92 ± 0.66, p = 0.032) and the postprandial urinary pH (6.29 ± 0.92 vs. 5.09 ± 0.73, p = 0.0001) following surgery. Conclusion: This study establishes that simple measurement of the urinary pH before and after a standard test meal can be used as an accurate routine test for the completion of vagotomy. It also showed that proton pump inhibitors abolish the alkaline tide and therefore must be discontinued before measuring the alkaline tide. Liquid test meal was not effective in eliciting an alkaline tide as compared to a solid meal.

Modulation of Alveolar Surfactant after Lower Cervical Vagotomy / 대한해부학회지

Pulmonary surfactant prevents alveolar collapse by reducing alveolar surface tension and aids gaseous exchange in the lung. Since inadequate production of pulmonary surfactant is a key etiological process in ARDS, surfactant may play an important role in pathogenesis of ARDS. To provide a clue for establishing pathological mechanism of post-traumatic or neurogenic ARDS, we studied the influence of the vagal innervation on pulmonary surfactant metabolism. A total of 20 S-D rats (about 230 gm wt. each) were divided into two conditions: normal control and vagotomized groups. The vagotomized rats were subdivided into 3 hours, 8 hours and 24 hours groups. To preserve the superior cervical cardiac branches, both vagus nerves were cut at the lowest part of the carotid triangle. Cannula for adequate respiration and suction was fitted into the trachea. The lung tissue were processed for H&E, Masson's trichrome, Immunohistochemistry using anti-surfactant protein A (SP-A) and .anti-prosurfactant protein C (ProSP-C). The results were as follows; 1. The lungs of the vagotomized rats showed alveolar edema, fibrosis with infiltration of inflammatory cells and hyaline membrane formation. 2. In the lungs of the vagotomized rats, SP-A and ProSP-C immunoreactivity was decreased in proportion to postoperation time. Consequently, it can be postulated that autonomic disturbances caused by vagal interruption may induce ARDS-like pulmonary damage by modulating alveolar surfactant protein metabolism and by evoking the secondary inflammatory processes.

Exclusão gastroduodenal e vagotomia troncular: repercussão no peso corporal e gastrinemia- estudo experimental em ratos / Gastroduodenal exclusion and truncal vagotomy: weight and seric gastrin alterations-experimental study on rats

Objetivo: A obesidade mórbida é uma doença crônica que se acompanha de várias complicações médicas e de uma menor esperança de vida, prejudicando o aspecto físico, emocional, econômico e social. As pesquisas clínicas e experimentais são amplamente justificadas nesta doença, considerando-se que a opção de tratamento operatório é recente. As gastroplastias e as derivações gástricas são algumas das modalidades terapêuticas propostas e produzem uma grande câmara gástrica remanescente, que em algumas técnicas fica totalmente excluída do trânsito alimentar. As possíveis alterações deste segmento, transformado em apêndice do sistema digestório, representam um vasto campo para pesquisa. Tivemos como objetivo avaliar o peso e as alterações da dosagem de gastrina sérica do rato, após denervação vagal troncular subdiafragmática, com exclusão da câmara gástrica e duodeno do trânsito alimentar do animal. Método: Foi realizada vagotomia troncular e exclusão gastroduodenal em cem ratos, dos quais trinta puderam ser estudados. Eram ratos machos adultos (Rattus Norvegicus Albinus), da linhagem Wistar, com peso médio de 378,67 g. Este estudo foi complementado pela dosagem sérica de gastrina por radioimunoensaio com I125 e duplo anticorpo para gastrina. Resultados: O peso de todos os ratos estudados diminuiu em média de 378,67 g para 285,83 g. Os trinta animais perderam em média 92,83 g (-24,52%). Houve diferenças significativas entre o peso inicial dos animais e o peso final (p< 0,001). A gastrina sérica tambémdiminuiu em vinte e um dos trinta ratos operados, caindo de 59,68 pg/ml para 46,77 pg/ml em média, correspondendoa uma diminuição de 12,91 pg ( 19,73%) entre as duas médias (p< 0,001). A análise estatística teve como objetivo avaliar se houve diminuição nas médias das variáveis: peso e gastrina, medidas antes e depois da operaçãoproposta. Para avaliar as diferenças entre as médias, utilizou-se o teste estatístico do T-Student...

Background: Morbid obesity is a chronic disease associated to severe medical complications, causing adverse effects on longevity as well as physical, emotional, social and economical consequences. Both clinical and experimental research have been addressing the surgical treatment. Gastroplasties and gastric bypasses have been developed, resulting in a relatively large gastric pouch where, in some techniques, is totally excluded from gastrointestinal transit. The possible alterations of that segment, transformed into an appendix of the digestory system, represents an interesting research area. Our aim was to evaluate the weight and the alterations of seric gastrin in rats after abdominal truncal vagotomy with exclusion of gastric pouch and duodenum. Methods: Thirty male adult Wistar rats (Rattus Norvegicus Albinus), out of one hundred, submitted to total gastric exclusion, with an average weight of 378.67 g, could be used in ourresearch. The study was complemented by the measurement of seric gastrin using radioimmunoassay I125 double antibody gastrin. Results: The weight of all studied rats decreased in average 92,83g (from 378,67g to 285,83g) which stands for a reduction of 24,52%. There were significant differences between the initial and final weights (p<0,001). Serum gastrin has also decreased in 21 out of the 30 operated rats from 59,68pg/ml to 46,77 pg/ml, corresponding to a decrease of 12,91pg (19,73%) between the two means (p<0,001). Statistical analysis was supposed to evaluate whether there was any decrease in the means of the following variables: weight and gastrin, measured before and after the surgical procedure. The T-Student statistical test was applied to evaluate such differences. Conclusions: There was a significant decrease of weight and serum gastrin after total gastric exclusion.

Effect of truncal vagotomy on biliary dynamics in dogs / 第三军医大学学报

Objective To explore the effect of truncal vagotomy on biliary dynamics in dogs.Methods After fasted for 18 h, 12 adult mongrel dogs underwent bilateral truncal vagotomy at the diaphragmatic level and pyloroplasty in the experiment group,and only pyloroplasty in the control group.All dogs were performed ultrasonograph to determine the size of the common bile duct(CBD) and sphincter of Oddi manometry(SOM) to detect biliary dynamics at postoperative 8 weeks,then the bile was collected from gallbladder for further analysis.Results In the experiment group,the CBD pressure,inner diameter of CBD,and SO basal pressure(SOBP) increased significantly,and sediments were found in the bile of all dogs,but SO amplitude(SOAP),frequency and duration of SO phasic contraction did not change.Conclusion Bilateral truncal vagotomy at the diaphragmatic level leads to significant increase of SOBP,resulting in a great change of biliary dynamics.

Extended parietal cell vagotomy for the treatment of acute perforation of duodenal ulcer / 中国普通外科杂志

Objective To evaluate the long-term results of extended parietal cell vagotomy (EPCV) for the treatment of acutely perforated duodenal ulcer. Methods EPCV was performed on 239 patients. Results were analyzed retrospectively. Results Follow up was made on 203 out of 239 patients (84.9%). There was no operative mortality. Inhospital complications included injury to the spleen in 4 cases (1.7%), adhesive ileus in 6(2.5%), acute diarrhea in 3 (1.3%), and postprandial epigastric distention in 18 (7.5%). Long-term complications included epigastric pain and sour regurgitation in 16 cases(7.8%), enterolysis in 4(1.9%), duodenal bulb allaxis in 39(18.2%), chronic gastritis in 21(10.3%), and recurrent ulcer in 6(2.9%). Basic acid output, maximal acid output and peak acid output decreased by 84.7%, 60.0%, and 58.0% respectively(all P

Modified Goligher high selective vagotomy in the treatment of duodenal ulcer: a report of 217 cases / 中国普通外科杂志

0.05), and both groups got ideal clinical effect. Conclusions MGHSV is an ideal operation for various types of duodenal ulcer, which with a preferable long-term effect. It is worth to be widely applied in clinical practice.