Metabolic effects of truncal vagotomy when combined with bariatric-metabolic surgery.

Bariatric-metabolic surgery (BMS) in patients with obesity frequently leads to remission of concurrent type 2 diabetes mellitus (T2DM), even before body weight loss takes place. This is probably based on the correction of a dysmetabolic cycle in the gastrointestinal physiology of T2DM that includes increased vagus-dependent exocrine pancreatic secretion (EPS) and, hence, amplified digestion and nutrient absorption. The resultant chronic exposure of tissues to high plasma levels of glucose, fatty acids and amino acids causes tissue resistance to the actions of insulin and, at a later stage, ß-cell dysfunction and reduction of insulin release. We hypothesize that the addition of a surgical truncal vagotomy (TV) may improve and solidify the beneficial results of BMS on T2DM by stably decreasing EPS, - hence reducing the digestion and absorption of nutrients -, and increasing incretin secretion as a result of increased delivery of unabsorbed nutrients to the distal intestine. This hypothesis is supported by surgical data from gastrointestinal malignancies and peptic ulcer operations that include TV, as well as by vagal blockade studies. We suggest that TV may result in a stable reduction of EPS, and that its combination with the appropriate type of BΜS, may enhance and sustain the salutary effects of the latter on T2DM.

Percutaneous CT-Guided Cryovagotomy.

There are a number of pathologic conditions in the human body that may be modified by the interruption of neural signaling, both related to pain and otherwise. Many of these treatments currently involve implantable neuromodulation or frank surgical neural ligation, representing opportunities for the implementation of percutaneous device-mediated cryoneurolysis in interventional radiology. Computed tomography-guided cryovagotomy for the management of mild to moderate obesity represents one such opportunity currently under investigation. This procedure is designed to attenuate hunger signals by targeting the posterior vagal trunk using computed tomography for cryoablation with a needle, based on historical surgical and electrical vagotomy experience. Future investigations of this technique and others will expand and iterate the concept of percutaneous, image-guided cryoneurolysis as potential management for a wide variety of clinical challenges.

The results of the surgical treatment of alkaline reflux gastritis.

BACKGROUND/AIMS: Alkaline reflux gastritis (ARG) is a major complication of gastric surgery. The symptoms of ARG may be intractable and remedial surgery may be required in this patients. The goal of this study was to present our experience reviewing surgical treatment of reflux gastritis. METHODOLOGY: During a 19-year period, we surgically treated 35 patients who had refractory ARG. Previously, gastric surgery was distal gastrectomy-gastrojejunostomy in 20 patients; truncal vagotomy-gastrojejunostomy in 11 and truncal vagotomy-pyloroplasty in 4 patients. Of 20 patients who underwent distal gastrectomy, 13 were treated with Roux-en-Y gastrojejunostomy, 6 with jejunal segment between the gastric pouch and duodenum (Henley technique) and one with conversion of Billroth II to Billroth I. Of 11 patients who initially underwent vagotomy-gastrojejunostomy, 8 were treated with Billroth II type gastrectomy and Roux-en-Y gastrojejunostomy and 3 with dismantling of a gastrojejunostomy, conversion of pyloroplasty. Four patients who originally underwent vagotomy pyloroplasty were managed with Billroth II type gastrectomy and Roux-en-Y gastrojejunostomy. RESULTS: Mortality rate of this series was zero. Long-term follow-up was obtained in 29 (83.0%) patients. According to Visick criteria, twelve patients (41.4%) reported exellent; ten (34.5%) good; three (10.3%) fair and four (13.8%) unsatisfactory results respectively. CONCLUSIONS: Remedial gastric surgery can be indicated in patients who had persistent ARG symptoms despite conservative management. Careful patient selection is essential to achieve best results.

Simultaneous/Incidental cholecystectomy during gastric/esophageal resection: systematic analysis of risks and benefits.

BACKGROUND: After esophageal/gastric resection with resulting truncal vagotomy, the incidence of gallstone formation seems to increase. The clinical relevance of gallstones and the role of simultaneous/incidental cholecystectomy in this setting are controversially discussed. METHODS: Systematic analysis has been performed for retrospective/prospective studies on the incidence/symptoms of gallstone formation after esophageal/gastric resection. Pooled estimates of the incidence of cholecystectomies were calculated by random effect models. Risk analyses of simultaneous, acute postoperative cholecystectomy and long-term cholecystectomy were performed. RESULTS: Sixteen studies on gallstone formation after upper gastrointestinal (GI) surgery (3,735 patients) reported increased incidences of 5-60% with a pooled estimate of 17.5% (95% confidence interval (CI), 14.1-21.2%; inconsistency statistic (I (2)) = 86%) compared with 4-12% in the control population. In 113 of 3,011 patients (12 studies), late cholecystectomies were performed for symptomatic cholecystolithiasis, corresponding to an estimated overall proportion of 4.7% (95% CI, 2.1-8.2%; I (2) = 92%). In 1.2% (95% CI, >0-3.7%; I (2) = 93%) of patients undergoing upper GI surgery, a cholecystectomy was performed because of acute postoperative biliary problems (4 studies, 8,748 patients). Simultaneous cholecystectomy had a higher morbidity of 0.95% (95% CI, 0.54-1.49%; I (2) = 28%) compared with the calculated additional morbidity of early and late cholecystectomy of 0.45%. CONCLUSIONS: Approximately 6% of patients undergoing upper GI surgery are expected to require cholecystectomy during follow-up. Because late cholecystectomies can be performed safely and because the additional calculated morbidity for these operations is lower than the morbidity for simultaneous cholecystectomy, it cannot generally be recommended to remove a normal acalculous gallbladder during upper GI surgery.

Partial gastrectomy associated to anterior truncal vagotomy: alterations in metabolism of the calcium. experimental study in rats / Gastrectomia parcial e vagotomia troncular anterior: alterações no metabolismo de cálcio. estudo experimental em ratos

BACKGROUND: The calcium is not absorbed in the lack of hydrochloric acid and the osteomalacia and osteoporosis may occurs; it is well recognized in patients that had gastric resection. AIM: To evaluate the effects of the partial gastrectomy associated to anterior truncal vagotomy in the absorption and metabolism of calcium. METHODS: Eighteen adults male Wistar rats were submitted to partial gastrectomy associated to anterior truncal vagotomy (GXT, eight animals) and the sham operation (10 animals, control group). The diet consumption and the weight gains of the animals were measured three times during the week. The animals received formulated experimental diet orally (AIN-93M) by eight weeks. The serum calcium, urinary and fecal calcium, apparent absorption of the calcium, activity of the enzyme alkaline fosfatase and calcium in the bone were measured after 60 days. RESULTS: The sham operated animals showed higher diet consumption, weight gains, serum and urinary calcium, excretion of calcium in feces, apparent absorption of calcium and activity of the enzyme alkaline fosfatase (P<0,05) as compared to the animals of the gastrectomized group. However, the concentration of the bone calcium was increased in the animals of the gastrectomized group. CONCLUSION: Partial gastrectomy associated to anterior truncal vagotomy showed to be a good experimental model the study calcium metabolism, decreasing the calcium absorption, serum and urinary calcium and activity of the enzyme alkaline fosfatase. However, for alterations at bone level in rats suggests an experimental study in larger period.

RACIONAL: O cálcio não é absorvido na ausência de ácido clorídrico e a osteomalácia e osteoporose podem ocorrer; este fato é bem reconhecido em pacientes que se submeteram à gastrectomias. OBJETIVO: Avaliar os efeitos da gastrectomia parcial associada à vagotomia troncular anterior na absorção e metabolismo de cálcio. MÉTODOS: Dezoito ratos Wistar machos e adultos foram submetidos à gastrectomia parcial e vagotomia troncular anterior (oito animais) e à laparotomia simples como grupo controle (10 animais). O consumo de dieta e o peso dos animais foram monitorados três vezes por semana. Os animais receberam dieta oral formulada experimentalmente (AIN-93M), durante 8 semanas. O cálcio sérico, cálcio urinário e fecal, absorção aparente de cálcio, atividade da enzima fosfatase alcalina e cálcio ósseo foram mensurados após 60 dias de observação. RESULTADOS: Os animais controle apresentaram médias estatísticas maiores (P<0.05) para o consumo de dieta, ganho de peso, cálcio sérico, cálcio urinário, excreção de cálcio nas fezes, absorção aparente de cálcio e atividade da enzima fosfatase alcalina comparados aos animais do grupo gastrectomizado. Entretanto, a concentração de cálcio ósseo foi superior no grupo de animais gastrectomizados (P<0,05) quando comparado com o grupo controle. CONCLUSÃO: A gastrectomia parcial associada à vagotomia troncular anterior mostrou ser um bom modelo experimental para estudo com o metabolismo de cálcio, ocasionando diminuição da absorção de cálcio, cálcio sérico, cálcio urinário e fosfatase alcalina. No entanto, para alterações a nível ósseo em ratos, sugere-se um estudo experimental em período maior.

[Acute intestinal obstruction after resection of the stomach and pylorus-destroying surgeries].

Results of examination of 55 patients with acute intestinal obstruction (AIO) who had undergone resection of the stomach (51) and trunk vagotomy with pyloroplasty (4) were analyzed. Among 29 operated patients AIO were caused by phytobezoars in 21 (72.4%) and comissures in 8 (27.6%) patients. Twenty-two were hospitalized in autumn. Twenty-six patients were treated conservatively, 12 of them were hospitalized in autumn. Small-intestine AIO due to phytobezoars is seen more often in patients with resected stomach. This pathology is characterized by triad of signs: the history of stomach resection, autumn (the season of haw), clinical picture of small-intestine obstruction.

Increased risk of cholelithiasis after esophagectomy.

BACKGROUND/PURPOSE: Truncal vagotomy enhances gallstone formation. As esophagectomy involves truncal vagotomy, it was hypothesized that esophagectomy would increase the risk of cholelithiasis. This study was intended to test this hypothesis and to elucidate factors influencing the incidence of cholelithiasis after esophagectomy. METHODS: The study was a retrospective analysis of 136 patients with esophageal carcinoma who had survived for 5 years or longer after esophagectomy. Eight patients (5.9%) had cholelithiasis before esophagectomy. Of the remaining 128 patients, 113 underwent abdominal ultrasonographic examination for cholelithiasis twice a year after esophagectomy; the median follow-up time was 89.5 months (range, 60-117 months). RESULTS: Gallstones developed in 26 (23%) of the 113 patients undergoing regular ultrasonographic examination. The cumulative incidence of cholelithiasis reached a plateau of 34% at 10 years after esophagectomy. Reduction of body mass index after esophagectomy was the strongest independent predictor of gallstone formation after esophagectomy ( P = 0.0001, log-rank test; P = 0.0003, Cox's proportional hazards model). The prevalence of cholelithiasis at 5 years after esophagectomy (18/113; 16%) was significantly higher than that before esophagectomy (8/136; 5.9%; P = 0.012, Fisher's exact test). CONCLUSIONS: Esophagectomy yields an increased risk of the development of cholelithiasis. Truncal vagotomy and postsurgical malnutrition may contribute to this increased gallstone formation after esophagectomy.

Acute vagotomy does not augment the systemic inflammatory response in patients with peptic ulcer disease.

Recent accumulating evidence suggests that the vagus nerve modulates the response to peripheral immunologic stimuli and that intact vagal mediation decreases the systemic inflammatory response. We hypothesized that patients who had vagotomy for complicated peptic ulcer disease would be at increased risk of an enhanced systemic inflammatory response compared to patients that did not have a vagotomy as part of their operative treatment. Ninety-six patients were identified from 1985 to 2000 and their medical records were reviewed. Patients were assigned to three groups based on the performance of a truncal vagotomy: truncal vagotomy (TV; N = 62 patients), nontruncal vagotomy (NTV; N = 34 patients), or a subgroup of the TV group, acute truncal vagotomy (ATV; N = 40 patients). Operative indications in the NTV and ATV groups were perforation (94% vs 47%) and bleeding (6% vs 53%). Systemic or organ-specific complications did not differ between groups (NTV vs ATV), and the sepsis (24% vs 23%) and mortality rates (29% vs 20%) were similar. The ICU and hospital length of stay did not differ substantially among the groups. This clinical study demonstrated that acute truncal vagotomy does not increase the risk of the systemic inflammatory response in surgical patients with complicated peptic ulcer disease.

Effect of truncal vagotomy on sphincter of oddi cyclic motility in conscious dogs.

OBJECTIVE: To evaluate the effects of truncal vagotomy at the diaphragmatic level on the sphincter of Oddi (SO) motility. SUMMARY BACKGROUND DATA: Cholelithiasis is a well-known late complication after gastrectomy and/or vagotomy. The mechanism of gallstone formation is only partly understood, and few studies address the effects of vagotomy on SO cyclic motility in conscious subjects. METHODS: In conscious dogs, SO motility was recorded by retrograde infusion manometry through a duodenal cannula before and after bilateral truncal vagotomy at the diaphragmatic level. Effects of cholecystokinin-octapeptide and feeding were also evaluated before and after vagotomy. RESULTS: SO cyclic motility and the gastroduodenal migrating motor complex continued to occur during postvagotomy fasting. Intermittent inhibitions of the SO and duodenal contractions disappeared during phase 3 of the migrating motor complex. SO basal pressure significantly decreased, whereas the amplitude significantly increased. Cholecystokinin-octapeptide inhibited SO contractions before and after vagotomy. The amplitude of SO contractions increased and their frequency decreased after feeding; however, these effects disappeared after vagotomy. CONCLUSIONS: SO cyclic motility and the effects of feeding change after truncal vagotomy at the diaphragmatic level. These facts may at least partly explain gallstone formation after gastric surgery and/or vagotomy.

Surgical management of peptic ulcer disease.

OBJECTIVE: To determine the pattern of surgically managed peptic ulcer disease. DESIGN: A retrospective study. SETTING: Department of Surgery, Moi Teaching and Referral Hospital, Eldoret, Kenya. SUBJECTS: Fifty three patients operated on for peptic ulcer disease. RESULTS: The mean age was 47 years with a male/female ratio of 1.7:1. Duodenal ulcer associated complications were the commonest with duodenal ulcer/gastric ulcer ratio of 11.5:1. Most patients had chronic peptic ulcer symptoms with inadequate or no medical treatment. Perforations were the commonest complications (56.6%) followed by gastric outlet obstruction (34.0%). Closure with omental patch was done in 83.3% of perforations while truncal vagotomy and drainage was done in gastric outlet obstruction. Hypostatic pneumonia was the commonest post-operative complication. Seventy one point seven per cent of the patients were free of dyspeptic symptoms during the brief follow-up period. CONCLUSION: Most patients with chronic peptic ulcers had had inadequate treatment and perforation was the most common complication. Repair of perforations with omental patch, and truncal vagotomy and drainage procedure for gastric outlet obstruction, were satisfactory surgical methods offered to patients at the Moi Teaching and Referral Hospital.

[Surgical correction of disorders of intestinal phases of gastric secretion in the treatment of peptic ulcer and its complications]. / Khirurgicheskaia korrektsiia narushenii kishechnoi fazy zheludochnoi sekretsii v lechenii iazvennoi bolezni i ee oslozhnenii.

Shown in the paper is a possibility of surgical correction of disturbances in the intestinal phase of gastric secretion in treating peptic ulcer and its complications which are encountered in an overwhelming majority of patients. Sympathectomy of relevant vascular trees is regarded as a pathogenetically validated procedure as is correction of duodenal motility combined with selective proximal vagotomy and excision of the ulcer. It is shown that truncal and selective vagotomy can aggravate the existing disorders of the intestinal phase of gastric secretion.

[Intestinal invagination after vagotomy in adults]. / Invagination intestinale après vagotomie chez l'adulte.

Intestinal intussusception is a rare condition in adults. In most cases, it is caused by a benign or malignant intestinal tumor. Primitive forms are infrequent, and their occurrence following troncular vagotomoy has never been described in the literature, according to our knowledge. Two cases of post-vagotomy jejuno-jejunal intussusception are reported.

Proximal gastric diverticulum after anterior lesser curve seromyotomy.

A case of gastric diverticulum arising in a patient who had previously undergone anterior lesser curve seromyotomy for chronic duodenal ulcer disease is reported. The endoscopic appearance of this lesion is described and the potential mechanisms of causation are reviewed. The clinical relevance of this rare finding is examined with emphasis on the need for an index of awareness of this abnormality on the part of endoscopists and in particular, on the risks of injudicious biopsy of such a diverticulum.

[Treatment of perforated duodenal ulcers]. / Traitement des ulcères duodénaux perforés.

Final surgical treatment of perforated duodenal ulcer is not admitted by all authors. The aim of this study is to evaluate final treatment of perforated duodenal ulcer among 110 patients. 74.5% were aged less than 41 years. 107 patients underwent surgery. Treatment was based on: truncal vagotomy with pyloroplasty (99 cases), truncal vagotomy with closure of duodenal perforation and gastroentero-anastomosis (5 cases), truncal vagotomy with antrectomy (1 case) and simple closure of the duodenal perforation (2 cases). Mortality of truncal vagotomy with pyloroplasty was about 1%. According to the visick evaluation, clinical results were good in 95.3% cases without recurrent ulcer with a mean follow up of 4 years. According to our results truncal vagotomy with pyloroplasty seems to be a safe procedure in the management of perforated duodenal ulcer and more over gives good long-term results in control of peptic disease.

[Truncal vagotomy using videothoracoscopy without gastric drainage. A prospective study of 250 cases surgically treated in Senegal]. / Vagotomie tronculaire par vidéothoracoscopie sans drainage gastrique. Etude prospective de 250 cas opérés au Sénégal.

AIM OF THE STUDY: The aim of this prospective study was to report early results of videothoracoscopic truncal vagotomy in non-complicated chronic duodenal ulcers. PATIENTS AND METHODS: From 1995 to 1998, 250 patients suffering from chronic duodenal ulcer without pyloric stenosis were operated on in the main hospital of Dakar. They underwent videothoracoscopic truncal vagotomy without gastric drainage. The quality of gastric emptying and the incidence of secondary side-effects were assessed in the postoperative course and after one and three months. RESULTS: There were two intraoperative deaths, one due to aortic wound and the other one due to a poor surveillance after premature extubation. Postoperative complications included bronchopulmonary infection (n = 9), one septic pleural effusion and one chylothorax. A postoperative gastroplegia occurred in 12 patients, which was always spontaneously regressive without endoscopic pyloric dilatation. After one month, 204 patients (82%) were classified Visik 1, and 44 (18%) classified Visik 2. An endoscopic control examination showed a healed peptic ulcer and open pylorus in all patients, and a gastric stasis present in 40 cases (16%). After three months and a new evaluation, 234 were classified Visik 1 (94%) and 14 Visik 2 (6%). Dumping syndrome was not observed in this series and the incidence of diarrhea, which was 40% after one month, decreased to 3% after three months. CONCLUSION: The functional results of truncular vagotomy without gastric drainage were good or very good and improved with time. The quality of digestive comfort and the low frequency of side-effects are good arguments in favor of this procedure as an elective treatment of duodenal ulcers in developing countries.