Vagotomy and subsequent risk of inflammatory bowel disease: a nationwide register-based matched cohort study.

BACKGROUND: The vagus nerve provides essential parasympathetic innervation to the gastrointestinal system and is known to have anti-inflammatory properties. AIMS: To explore the relationship between vagotomy and the risk of inflammatory bowel disease (IBD) and its major categories: Crohn's disease (CD) and ulcerative colitis (UC). METHODS: A matched cohort comprising 15 637 patients undergoing vagotomy was identified through the Swedish Patient Register from 1964 to 2010. Each vagotomised patient was matched for birth year and gender with 40 nonvagotomised individuals on the date of vagotomy. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for IBD using flexible parametric models adjusted for matching variables, year of vagotomy, birth country, chronic obstructive pulmonary disease and comorbidity index. RESULTS: We observed 119 (0.8%) patients with vagotomy developed IBD compared to 3377 (0.5%) IBD cases in nonvagotomised individuals. The crude incidence of IBD (per 1000 person-years) was 0.38 for vagotomised patients and 0.25 for nonvagotomised individuals. We observed a time-dependent elevated risk of IBD associated with vagotomy, for instance, the HR (95% CI) was 1.80 (1.40-2.31) at year 5 and 1.49 (1.14-1.96) at year 10 post-vagotomy. The association appeared to be stronger for truncal than selective vagotomy and limited to CD (HR was 3.63 [1.94-6.80] for truncal and 2.06 [1.49-2.84] for selective vagotomy) but not UC (1.36 [0.71-2.62] for truncal and 1.25 [0.95-1.63] for selective vagotomy). CONCLUSIONS: We found a positive association between vagotomy and later IBD, particularly for CD. The finding indirectly underlines the beneficial role of the vagal tone in IBD.

Trends and predictors for vagotomy when performing oversew of acute bleeding duodenal ulcer in the United States.

BACKGROUND: In the era of Helicobacter pylori treatment, the role of vagotomy in bleeding duodenal ulcers is debatable. National outcomes were evaluated to determine the current surgical treatment and use of vagotomy for bleeding duodenal ulcers. METHODS: Data from the Nationwide Inpatient Sample (NIS) were used from years 1999 to 2003. Patients were selected using diagnostic codes for acute duodenal ulcer bleed and procedure codes for simple oversew of a bleeding ulcer and vagotomy. Data were analyzed using multiple linear and logistic regression. RESULTS: Between 1999 and 2003, 100,931 patients with an acute bleeding duodenal ulcer were identified. Over time, there was a decrease in the number of acute bleeding ulcers (p = 0.027) and a decrease in the number of vagotomies (p = 0.027). A high co-morbidity index [odds ratio (OR), 0.60, p = 0.017], operation in the Midwest (OR 0.50, p < 0.001) and operation in the West (OR 0.68, p = 0.034) were predictive of no vagotomy during surgery for a bleeding duodenal ulcer. CONCLUSIONS: A vagotomy is not commonly performed during surgical treatment of an acute bleeding duodenal ulcer. This variation in practice was not fully explained by patient characteristics. We must seek new evidence to determine the safety of combined medical and surgical management of this clinical problem.

Malignant disease in peptic ulcer surgery patients after long term follow-up: a cohort study of 1992 patients.

AIMS: To assess the effect of previous peptic ulcer surgery on subsequent malignant events, in particular in relation to previous vagotomy, a historical cohort study was conducted. METHODS: All patients undergoing surgery for peptic ulcer disease with accurate follow-up data at a large peptic ulcer clinic in the Western Infirmary, Glasgow, from 1965 to 1983 were assessed. All cancer events and specific cancer events (gastric, bronchial, laryngeal, colorectal, bladder, breast, prostate, pancreas, kidney, oesophageal cancers) were determined as outcome measures and expressed as standardised incidence ratio (SIR). RESULTS: Vagotomy and drainage accounted for 67% of all procedures for peptic ulcer disease. Eighty-three percent were habitual smokers. For all peptic ulcer surgery patients, the SIR for all cancer events was 0.86. For specific cancers, the SIRs were bronchial cancer (SIR 1.13); laryngeal cancer (SIR 2.17), colorectal cancer (SIR 0.67). For vagotomised patients the risk of gastric cancer was significantly elevated (SIR 1.50). CONCLUSIONS: An excess of cancers attributable to smoking have been found in peptic ulcer surgery patients. Vagotomised patients have a higher risk of gastric cancer after long term follow-up. This finding may have implications for screening and the safety of long term acid suppression with agents such as proton pump inhibitors.

Inhibition of fibrin-induced neurogenic pulmonary edema by previous unilateral left-vagotomy correlates with increased levels of brain nitric oxide synthase in the nucleus tractus solitarii of rats.

In the course of investigations on mechanisms underlying development of neurogenic pulmonary edema (NPE), we have evaluated effects of nitric oxide (NO) in the central nervous system on incidence and severity in the fibrin-induced pulmonary edema model. Rats left-unilaterally vagotomized 1, 2 and 4 weeks before injections of fibrinogen and thrombin into the cisterna magna, after cutting the right vagus nerve, grouped as LVIW, LV2W or LV4W, respectively. The brain NO synthase (NOS) mRNA level in the left medulla oblongata was elevated in the LV2W group, compared to the control, but decreased in the LV4W rats. Incidences of pulmonary edema were 100% in the control group, decreasing to 78% in LV1W group, 17% in LV2W group, and back to 72% in LV4W group. The lung water ratio, a parameter of severity, demonstrated a similar pattern of change as the incidence. The lowered incidence and severity obtained in the LV2W group were reversed by intracisternal injection of N-nitro-L-arginine methyl ester (L-NAME). From these results, we propose that an increase in nitric oxide, possibly in the nucleus tractus solitarius 2 weeks after left vagotomy, may have an inhibitory action on the development of neurogenic pulmonary edema in rats.

Subdiaphragmatic vagal afferent innervation in activation of an opioidergic antinociceptive system in response to colorectal distension in rats.

Abstract In a number of different experimental paradigms of somatic pain, there is evidence for a vagally mediated antinociceptive system. This pathway probably involves opioid mechanisms. However, whether this pathway is activated in visceral pain or if it involves subdiaphragmatic vagal afferents is unclear. The aim of the present study was to determine whether subdiaphragmatic vagal afferents mediate antinociception in response to a visceral stimulus and whether this involves an opioid pathway. Colorectal distension was performed in fasted, conscious male Sprague-Dawley rats using a balloon catheter connected to an electronic distension device. The number of abdominal contractions (visceromotor response) in response to a tonic colorectal distension (60 mmHg for 10 min) was recorded. Experiments were performed in sham or subdiaphragmatically vagotomized, perineural vehicle- or capsaicin-treated rats (to functionally denervate vagal afferents) before and after administration of naloxone (25 mg kg(-1) bodyweight intraperitoneally). Vagotomy, capsaicin and naloxone pretreatments all significantly enhanced the visceromotor response to colorectal distension. The effect of naloxone in capsaicin-treated rats did not appear to be additive. These results suggest that activation of subdiaphragmatic afferents, which can be blocked by capsaicin, may play a role in opioid-dependent antinociceptive pathways activated by a noxious visceral stimulus.

Baroreceptor-related dysrhythmias in piglets with selective autonomic denervation of the heart.

This study was carried out to determine whether selective cardiac autonomic denervation performed on neonatal swine would evoke dysrhythmias later in development. Piglets (n = 27; 5-10 days old) underwent unilateral stellate ganglion ablation, or right cardiac vagotomy, or sham surgery. Fifty to sixty days after denervation, acute experiments were performed to evaluate responses to baroreceptor activation. Of all animals who exhibited prolonged R-R intervals, only those with right stellate ganglion ablation had prolonged corrected QT intervals. Despite findings suggesting an arrhythmogenic state (predominance of left-sided cardiac innervation), dysrhythmias occurred in all animals with stellate ganglion ablation, regardless of laterality, but in few vagotomized or control animals. Our results suggest that partial sympathetic innervation may alter cardiac function so that dysrhythmias are more likely to occur during baroreceptor activation.

Recent trends in admissions and mortality due to peptic ulcer in England: increasing frequency of haemorrhage among older subjects.

BACKGROUND: Although overall admission rates for peptic ulcer in England declined from the 1950s up until the mid 1980s, perforations among older women increased, possibly due to increasing use of non-steroidal anti-inflammatory drugs (NSAID). Since then, proton pump inhibitors, antibiotic treatment for Helicobacter pylori, low dose aspirin, and selective serotonin reuptake inhibitors (SSRI) have been introduced Aims: To determine time trends for hospital admissions for peptic ulcer from 1989 to 1999 (England), mortality from 1958 to 1998 (England and Wales), and prescriptions for ulcer healing drugs, aspirin, NSAID, oral anticoagulants, and SSRI from 1990 to 1999 (England). METHODS: Hospital episode statistics for admissions and mortality were obtained from the Office of National Statistics: community prescription data from Statistics Division 1E of the Department of Health. RESULTS: Between 1989/90 and 1998/99, there was a marked rise in admissions for haemorrhage in older patients, particularly from duodenal ulcer. Perforations from gastric ulcer declined but perforations from duodenal ulcer increased among men at older ages. Since the mid 1980s mortality has declined in all age groups except for older women with duodenal ulcer. The number of prescriptions for histamine H(2) receptor antagonists remained constant but those for proton pump inhibitors increased by 5000%, aspirin 75mg by 460%, oral anticoagulants by 200%, and NSAID by 13% between 1990 and 1999. Since the introduction of SSRI in 1991, prescriptions have increased 15-fold. CONCLUSIONS: Admission rates for gastric and duodenal ulcer haemorrhage and duodenal ulcer, but not gastric ulcer perforation, increased among older subjects, over a time when prescriptions for proton pump inhibitors, low dose aspirin, oral anticoagulants, and SSRI increased.

[The surgical aspects of the treatment of stomach cancer]. / Khirurgicheskie aspekty lecheniia raka zheludka.

The authors made an analysis of surgical treatment of 348 patients with different localizations and morphological forms of gastric cancer. It was shown that the formation of areflux anastomoses allowed the frequency of postoperative complications to be reduced to 13.2% and lethality to 2.4%.

Utilización de métodos experimentales para constatar procesos degenerativos en trayectos nerviosos: una ayuda para comprobar la evolución de la degeneración nerviosa en animales vagotomizados vagotomizados / Utilization of experimentals methods to verify degenerations lapses in nervous distance: a help to confirm the evolution of degeneration lapse in vagotomized animals

Se presentan los hallazgos en relación al patrón de degeneración nerviosa observando en los estómagos de 25 ratas albinas y 8 perros. Ambos tipos de animales fueron divididos en dos grupos, un primer grupo fue sometido a vagotomía por las técnicas convencionales y un segundo grupo fue intervenido con microcirugía. Los tiempos de superviviencia permitidos fueron desde 24 horas hasta 5 meses. Las muestras de estómago fueron procesadas por parafina y luego sometidos a diversas técnicas de coloración y de impregnación. Se correlacionaron los patrones de degeneración con el tipo de intervención quirúrgica practicada

Cirugía laparoscópica avanzada / Advanced laparoscopic surgery

El vertiginoso y exitoso desarrollo de la colecistectomía laparoscópica ha orientado este abordaje hacia la resolución de otras patologías quirúrgicas. Es lo que se conoce como cirugía laparoscópica avanzada. Iniciamos un registro prospectivo en el programa Epi Info 5.01, en diciembre de 1996. Hasta julio de 1997 hemos operado 17 pacientes, 10 mujeres y 7 hombres, de 27 a 56 años. Fueron 6 vagotomías supraselectivas, 4 fundoplicaturas, 2 de ellas con hernia hiatal, se les agregó cierre del hiato, 4 gastroplastias en obesidad mórbida, una quistoperiquistectomía parcial en quiste hidatídico hepático y 7 coledocostomías. No hubo morbimortalidad atribuibles a las técnicas empleadas. Hubo satisfacción en los enfermos operados, no hay a la fecha recidiva ulcerosa ni de reflujo gastroesofágico. Los obesos mórbidos han bajado 8 kg por mes y aún no alcanzan su estabilización ponderal. Consideramos que la cirugía laparoscópica avanzada puede ser empleada por cualquier cirujano diestro en colecistectomía laparoscópica y con experiencia en las técnicas de cirugía convencional

[The outcomes of the surgical treatment of a bleeding duodenal ulcer at a specialized provincial center]. / Iskhody khirurgicheskogo lecheniia krovotochashchei iazvy dvenadtsatiperstnoi kishki v oblastnom spetsializirovannom tsentre.

Gastroduodenal bleedings were surgically treated in 244 patients with bleeding duodenal ulcers at the regional specialized center of treatment of gastroduodenal bleedings during 5 years. Postoperative lethality was 9.4%. A classification of surgical operations for bleeding ulcers is proposed depending on the time of performing. Substantiation is given to expediency of specialized medical care of such patients at the specialized center.

[Prevalence of Helicobacter pylori infection in gastrectomy and vagotomy]. / Prevalencia de la infección por Helicobacter pylori en la gastrectomía y en la vagotomía.

OBJECTIVE: To report the prevalence of Helicobacter pylori infection in patients undergoing gastrectomy or vagotomy plus pyloroplasty because of peptic ulcer disease. METHODS: Eighty-five patients were studied (mean age = 61 years; 85% males) who had undergone gastric surgery: Billroth I gastrectomy (n = 25), Billroth II (n = 51) and vagotomy plus pyloroplasty (n = 9). During endoscopy biopsy specimens were obtained from fundus and both sides of anastomosis for histological (hematoxylin-eosin) and microbiological (Gram stain and culture) investigations. RESULTS: The overall percentage of Helicobacter pylori infection was 43.6% (Billroth I = 40%; Billroth II = 37%; vagotomy = 89%) and no differences were observed between both types of surgical reconstruction. However, differences were indeed observed (p < 0.01) when comparing percentages of infection between patients undergoing gastrectomy and vagotomy. Among infected gastrectomized patients H. pylori was detected in fundus in 93% of cases, whereas the recovery rate from anastomotic mouth biopsies was only 72% (p < 0.05). CONCLUSIONS: The prevalence of H. pylori infection in gastrectomized patients (Billroth I and II) was low regarding the cause of surgery (peptic ulcer disease), and no differences were observed between both types of surgical reconstruction. The prevalence of infection after vagotomy and pyloroplasty was significantly higher. Among infected gastrectomized patients, H. pylori was detected more frequently in gastric fundus compared with biopsy specimens obtained from the anastomotic mouth.

[The choice of the type of vagotomy in the planned surgery of peptic ulcer]. / Vybor vida vagotomii v planovoi khirurgii iazvennoi bolezni.

An analysis of 175 organ preserving operations for duodenal ulcer is presented. Lethality was 1.24%; intraoperative complications--2.48%; postoperative complications--6.83%. Long-term results were followed in 61.5% of the patients. They are analyzed according to the kind of vagotomy and draining operations used. The author recommends to use drainage of the stomach more often, combined vagotomy should be chosen as the kind of vagotomy.

[Surgical treatment of stomach ulcer]. / Khirurgicheskoe lechenie iazvy zheludka.

The choice of the operative method in gastric ulcer is determined by the peculiarities of ulcer development mechanism and the role of acid production in the process and by oncological reasons. Bearing in mind that acid production is of little significance in the pathogenesis of gastric ulcer, while malignant degeneration of gastric ulcers is quite a reality, the authors consider resection of the stomach to be the most expedient operative method in its ulcer. Among 73 patients with gastric ulcer 70 (95.94%) were treated by resection of the stomach. Depending on the localization of the ulcer, the volume of the resection ranged from antrumectomy to gastrectomy. Five (7.14%) patients died after the operation, 3 from thromboembolic complications and 2 from peritonitis. The late-term, results were studied in 53 (81.54%) patients and were found to be good in 44 (83.02%), satisfactory in 5 (9.43%), and poor in 4 (7.55%) patients. Malignant degeneration of the ulcer was encountered in 7 (10%) of the 70 patients who were operated on. The authors prefer resection of the stomach with the formation of Roux-en-Y anastomosis which prevents reflux gastritis, recurrent ulcer, and the development of tumors. This is confirmed by the late-term results.

[The prognosis of the late results of vagotomy and dispensary care in patients with duodenal peptic ulcer]. / Prognozirovanie otdalennykh rezul'tatov vagotomii i dispanserizatsii bol'nykh iazvennoi bolezn'iu dvenadtsatiperstnoi kishki.

The article studies the remote results of vagotomy in treatment of 212 servicemen with ulcer of duodenum. Laboratory, endoscopic, roentgenological, pH-metric, manometric, radioimmunological and morphological researches were used before and after operations. From the point of view of prognostication 30 important criteria were selected to forecast the results of vagometry, and also to determine the groups for control examination. These data made it possible to prognosticate the right outcomes of treatment in 84.7% of cases, and thus individualize the treatment and prophylaxis of the prior disease and postvagotomy syndromes reducing their frequency. In the results of these measures the cases of invalidity and disability retirement of servicemen were diminished.

[The immediate and late results of vagotomy in a bleeding pyloroduodenal ulcer]. / Neposredstvennyi i otdalennyi rezul'tat vagotomii pri krovotochashchei piloroduodenal'noi iazve.

A 10-year experience with the use of vagotomy with the organ-preserving intervention in the treatment of patients with a bleeding pyloroduodenal ulcer who were treated for urgent and emergency indications is presented. The postoperative mortality was 8.1%. An excellent and good long-term result was noted in 88% of the patients, an unsatisfactory one--in 12%.

[The modern aspects of the surgical treatment of the perforated gastric and duodenal ulcer with a view to the immediate results]. / Suvremenni aspekti pri khirurgichnoto lechenie na perforiralata stomashna i duodenalna iazva s ogled na neposredstvenite rezultati.

Experience is recorded with the operative treatment of 185 patients with perforated gastric and duodenal ulcer over the period 1981-1991. The period was divided in two: 1981-1985 and 1986-1991. During the first period were operated 89 patients: 58 with perforated duodenal ulcer and 31 with gastric ulcer. The method of choice during this period was suture of the perforation. During the second period were operated 96 patients: 90 with duodenal and 6 with gastric ulcer. Surgical approach was also individualized depending on the pathologic process, patient age and accompanying diseases. The following operative interventions were performed: "pure suture" of the ulcer--55 patients; gastric resection by Billroth I and II techniques--7 patients; different variants of vagotomy with drainage operation--34 patients. Analysis of the immediate results in 42 patients demonstrated that best results were obtained by vagotomy + drainage operations.

[A retrospective survey study of diagnosis and surgical treatment in peptic ulcer]. / Obzorno retrospektivno prouchvane vurkhu diagnozata i khirurgichnoto lechenie na iazvenata bolest.

A total of 239 patients of which 183 operated over the period 1987 through 1992 are reviewed. Cases with duodenal location of the lesion predominate (84 per cent), next ranking gastric ulcers (14 per cent), and type II according to Johnson (2 per cent). Among the patients operated on resection methods, type Billroth II, with antecolic gastroenteroanastomosis and Braun's anastomosis, accounting for 84.1 per cent of the total of planned operations, are mainly used. Retrocolic gastroenteroanastomosis type Hoffmeister-Finsterer is performed in five, and Billroth I-in one patient. Three patients presenting gastric ulcer, free of malignization signs, are subjected to pylorus-preserving resection according to MacKee. Resection methods as a definitive therapeutic approach to ulcers, at that according to Billroth II, are predominant owing to the fact that most patients operated on present ulcers penetrating the pancreas, involving ligamentum hepatoduodenale and the descending portion of the duodenum, and pyloric stenosis, making impossible the restoration of passage by Billroth I or other operations. A lasting good result is attained in 92 per cent of cases, minor complaints are recorded in 6 per cent, and substantial complaints-in 2 per cent. The study results lead to the inference that standard resections with anterior gastroenteroanastomosis in complicated ulcers, ruling out other alternatives, yield a permanent therapeutic effect. The approach to individual patients should be by no means unified, and the most expedient operative procedure should be used. Owing to delayed operative treatment and numerous complications, the classical resection methods prove to be the method of choice in the surgical management of ulcers.

[The surgical procedure in patients with hemorrhaging perforating gastroduodenal ulcers]. / Khirurgicheskaia taktika u bol'nykh s krovotochashchimi penetriruiushchimi gastroduodenal'nymi iazvami.

The paper presented the results of surgical treatment of 277 patients with bleeding penetrating gastroduodenal ulcers. Gastric location of the ulcer was revealed in 52 patients and duodenal location in 225 ones. More commonly used resections of the stomach according to a Billroth-I method or suprapyloric resections versus the resection of the stomach according to method Billroth-II when used in the patients with gastric location of the ulcers helped to reduce the mortality from 23.1 to 0%. The wide usage of organ-sparing operations combined with vagotomy reduced the lethal outcomes of the disease from 13 to 5.5% versus the resection of the stomach. The rate of bleeding relapses in the early postoperative period which followed the suture of penetrating gastroduodenal ulcers was 25.9%. The dissection of ulcers or their elimination from the alimentary tract could be regarded as the methods of choice in case of palliative treatment. Surgical treatment of penetrating gastroduodenal ulcers should be performed prior to bleedings. Planned operative intervention should be performed in patients with deep gastric ulcer with diameter of 1.5 cm and more and pyloroduodenal ulcers with diameter of more than 1 cm.