Laparoscopic highly selective vagotomy.

Laparoscopic highly selective (anterior and posterior) vagotomy was performed in 11 patients for duodenal ulcer (n = 10) and duodenal ulcer with prepyloric ulcer (n = 1). All patients were endoscoped both pre- and postoperatively. There were no perioperative complications. The average operating time was 3.2+/-0.4 hours and the average hospital stay was 1.7+/-0.2 day (range 1 to 3 days). None of the patients required parenteral narcotics postoperatively. The patients have been followed for 6 months to 5 years after operation. All ulcers healed as demonstrated by endoscopy. There was one recurrence at 9 months in a patient who had a prepyloric ulcer preoperatively. The recurrence was treated successfully with medication. There has been no other long-term morbidity. Laparoscopic highly selective vagotomy is feasible, safe, requires a brief hospital stay, and produces short-term results comparable with open surgery.

Surgical treatment of peptic ulcer disease: changing patterns in the past 40 years.

During the past 40 years (1951-1990), 7,663 patients with peptic ulcer disease underwent surgical treatment at the National Taiwan University Hospital. A great change in patient characteristics and operative procedures was noted between the last 10 years and the previous three decades. There were 7,105 patients (92.7%) between 1951 and 1980, an average of 237 patients per year. However, only 558 patients received surgery in the last 10 years, an average of 56 patients per year. The proportion of female patients increased from 9.5% in the earlier period to 20.4% in the last 10 years; the average age of patients also increased. In the earlier period, the indications for surgery were hemorrhage (38.4%), perforation (36.1%), intractable pain (16.4%) and stenosis (9.1%). Perforation (89.2%) was the most common indication for surgical treatment in the last 10 years. Hemorrhage (4.9%), pain (4.1%) and stenosis (1.8%) were less common. There was no significant difference in surgical morbidity between the two periods. Primary subtotal gastrectomy (SG) accounted for 75.4% of operations in the earlier period, but vagotomy became the main treatment in the last 10 years, including highly selective vagotomy (HSV) (31.9%), and truncal vagotomy with drainage procedure (TV + D) (31.0%). The surgical mortality in the earlier period was 1.3% for SG, 1.8% for TV + D and 16.1% for simple closure. There was no significant change in ulcer location between the two periods. The overall mortality rate was higher in the last 10 years (5.2%) than in the earlier 30 years (2.7%) (p < 0.001). In follow-up studies, the satisfactory rate after operation was similar among patients receiving SG (89.8%), HSV (90.3%) and TV + D (91.1%) between 1977 and 1990.

[Is there to be a renaissance of surgical treatment of ulcers?]. / Vil kirurgisk ulcusbehandling få en renaessance?

Medical treatment of peptic ulcer disease with H2-blockers has over the last ten years practically replaced surgical treatment of this condition, due to greater patient compliance, high effectivity and negligible side-effects. The treatment is, however, strained by the relatively high cost of medication. Development of techniques for laparoscopic vagotomy, which is associated with a considerably reduced postoperative morbidity and reconvalescence as well as entailing only one to two days hospitalization and a minimal surgical scar, has re-opened the debate on medical versus surgical treatment of ulcers. On the basis of a literature review of risk of ulcer recurrence, risk of ulcer complications, cost and compliance associated with the two types of treatment, it is concluded that surgical treatment of peptic ulcers by laparoscopic parietal cell vagotomy should have a renaissance as regards the treatment of patients, who have frequent recurrences when maintained on ordinary medical treatment. However, the development of new, alternative principles for the cheap, effective and complication-free medical treatment of these patients, for example via elimination of helicobacter pylori infection, will necessitate a re-evaluation as regards the treatment of choice.

[Potential for developments in ulcer surgery]. / Entwicklungspotentiale in der Ulkuschirurgie.

Historically, surgery for peptic ulcer has seen the evolution of differing operative principles: resection, vagotomy (truncal, selective, highly selective), and a combination of vagotomy and resection (antrectomy). The long-term effects of the various operations can now be evaluated from several published studies. Though vagotomy and antrectomy is the most "efficient" operation (ulcer recurrence rate 1%), it has the highest morbidity (15-20%) and mortality (1.5-2%); while highly selective vagotomy is the least "efficient" operation (ulcer recurrence rate 10%), it has the lowest morbidity (5%) and mortality (less than 0.5%). In the future, reduced recurrence rates should be possible by improving surgical technique and by better selection of the operative procedure (on the basis of a better selection of the operative procedure (on the basis of a better understanding of ulcer pathogenesis), but without sacrificing the advantages of highly selective vagotomy--low morbidity and mortality--for the majority of patients. Intraoperative testing of the completeness of vagotomy, and addition of a drainage such as pyloroplasty or antrectomy for juxtapyloric ulcers, may help to achieve this goal.