The vagal nerve as a link between the nervous and immune system in the instance of polymicrobial sepsis.

BACKGROUND: The role of the vagal nerve in the autonomic nervous system is widely well known. Recently, an additional function was revealed serving as a connector between the nervous and immune system. This connection is called the "cholinergic inflammatory pathway." Through stimulation of the acetylcholine receptors located upon the macrophages, the "unspecific" immune system can be directly influenced. METHODS: The vagal nerve was completely transected directly posterior to its passage through the diaphragm. The effect of complete vagotomy was analyzed using a murine model of polymicrobial peritonitis (colon ascendens stent peritonitis, CASP). Survival and clinical course of vagotomized or sham-operated mice were analyzed in the CASP model. RESULTS: After CASP surgery, vagotomy led to a significantly increased mortality (64.7%) in comparison to sham-vagotomized animals (34%). No difference in the bacterial load of various tissues (lung, liver, spleen, blood, lavage fluid, and kidney) from septic animals with or without vagotomy was observed. Vagotomized animals reveal elevated serum cytokine levels (TNF, IL-6, IL-10, and MCP-1) 20 h after the induction of polymicrobial peritonitis. CONCLUSION: The vagal nerve is therefore an important modulator of the immune system.

[Vagotomy in surgical treatment of duodenal ulcer]. / Rol' i mesto vagotomii v khirurgicheskom lechenii iazvennoi bolezni dvenadtsatiperstnoi kishki.

Results of organo-saving operations in 807 patients (72% men, 28% women) with duodenal ulcers were analyzed. Bilateral truncal vagotomy (with pyloro-, duodenoplasty, gastroenterostomy, gastroduodenostomy, economical stomach resection) were performed in 27.1% patients, selective--in 1.4%, selective proximal--in 65.5%, anterior selective and posterior truncal vagotomy--in 6.0%. Lethality was 1.6%, long-term results were excellent and good in 75.6% cases. Satisfactory results were seen in 8.6% patients, bad results--in 15.8%.

[Perioperative mortality for perforated duodenal and gastric ulcer--analysis of 226 patients]. / Smiertelnosc okolooperacyjna w przedziurawionym wrzodzie dwunastnicy i zoladka--analiza 226 chorych.

Between 1988 and 1997 in 226 patients (169 males--75.2% and 57 females--24.8%) surgical treatment was performed due to duodenal ulcer perforation (205 cases--90.7%) or gastric ulcer perforation (21 cases--9.3%, including 3 cases of perforated gastric cancer). Mean age was 51.5 years (19-94 years). In perforated duodenal ulcer the main procedure was truncal vagotomy with pyloroplasty performed in 95.6%, and simple ulcer suture in 4.4%. In perforated gastric ulcer the main procedure was Billroth I (Rydygier) stomach resection performed in 76.18%, and simple ulcer suture in 23.82%. A group of patients who died in perioperative period (29 cases--12.8%) was selected and compared to a group of others regarding age, sex, smoking, alcohol abuse, time elapsing between first symptoms and surgical treatment, use of NSAIDs, location and size of perforation hole, type of surgical procedures. On that basis 4 risk factors of disease in perioperative period due to perforated ulcer surgery were appointed: 1. Age--mean age of patients who died was 67 years (vs. 48.9 years among successfully treated), perioperative mortality in patients over 60 years old was 35.4%, and in patients over 70 years old was 50%). 2. Presence of three or more coexisting diseases--54.54% risk of disease (vs. 2.5% in patients with less than three or without coexisting diseases). 3. Delay in surgical treatment over 24 hours--48.15% of diseases vs. 7.04% in patients undergoing surgery within the first 24 hours following perforation. 4. Septic shock--80% of diseases.

[Evaluation of early and late results of radical treatment for perforated duodenal ulcer]. / Ocena wczesnych i odleglych wyników radykalnego leczenia przedziurawionego wrzodu dwunastnicy.

The results of the emergency radical treatment of 285 patients with perforated duodenal ulcer are discussed. The authors compared 4 surgical techniques: 1) truncal vagotomy with traditional antrectomy, 2) truncal vagotomy with mucosal antrectomy, 3) truncal vagotomy with pyloroplasty, and 4) proximal gastric vagotomy. The best early results have been achieved in case of the proximal gastric vagotomy. However, the best late results have been noted in case of vagotomy with mucosal and traditional antrectomy. The overall perioperative mortality was 3.5%. Recurrent ulcer has been mainly observed in patients operated with proximal gastric vagotomy several years after the surgery.

Elective treatment of bleeding varices with the Sugiura operation over 10 years.

A 10-year experience with the devascularization operation described by Sugiura is reported here. The operation was performed electively in 100 patients in whom it was not possible to place a shunt, all of whom had different kinds of hepatopathies (63 Child's A, 32 Child's B, and 5 Child's C). In 15 patients, the procedure was done in one stage (6% operative mortality, 1 patient), and, in 51, it was performed in two stages. Eight deaths were recorded in the 63 patients of the Child's A group, with a total of 111 operations. The operative mortality rate for this group was 12% and, as related to the number of operative procedures, 7% (8 of 111 operations). Seventeen patients were not considered for a second stage. Rebleeding in the early postoperative period was 4% and at long-term 6%. Incapacitating encephalopathy was found in 2 of the 71 surviving patients (3%). Survival (as determined by Kaplan-Meier tests) was 75% (1 year), 70% (5 years), and 69.2% (10 years). Six esophageal fistulas were observed secondary to transection. The Sugiura operation is an excellent complement to the therapeutic armamentarium used to treat portal hypertension, with low rebleeding and encephalopathy rates.

Management of benign, giant gastric ulcers.

Giant gastric ulcers (greater than 3 cm in diameter) have traditionally been considered to be refractory to medical therapy and were commonly thought to initially appear as life-threatening hemorrhage requiring emergent operative therapy. This study was undertaken to evaluate the results of medical and surgical treatment of benign, giant gastric ulcers and the validity of these traditional teachings. A retrospective review of 44 patients with giant gastric ulcers was performed to evaluate the results of medical and surgical therapy at Hartford Hospital (Hartford, CT). The majority of these patients received medical therapy. Over 57 per cent received only medical therapy, while 25 per cent received primary, operative therapy. Contrary to popular belief, the authors found that patients who received initial medical therapy did not have high morbidity or mortality rates. Therefore, while the necessity of early surgical intervention following perforation or in patients with signs of hemorrhagic shock can not be refuted, the authors conclude that medical therapy of benign, giant gastric ulcers is often effective and not unduly hazardous. Giant gastric ulcers, in and of themselves, are not an indication for surgery.

[Organ-sparing operations in bleeding ulcers of the pylorus and duodenum]. / Organosokhraniaiushchie operatsii pri krovotochashchikh iazvakh privratnika i dvenadtsatiperstnoi kishki.

The organ-preserving operations were performed in 387, gastric resection--in 142, closure or excision of an ulcer without vagotomy--in 132 patients with bleeding pyloroduodenal ulcers. The lethality after gastric resection was 11.3%: after the emergency operations--16.3%; after early elective interventions--9.1%; after the organ-preserving operations--2.6, 5.3, 0.85%, respectively.

Trends in the surgical management of duodenal ulcer. A fifteen year study.

The number of patients undergoing definitive duodenal ulcer operation at Charlotte Memorial Hospital and Medical Center declined by 75 percent from 1971 to 1985. The percentage of women making up the total study population increased to 40 percent in the period from 1981 through 1985. Average patient age also increased. Fewer gastric resections are now being performed and emergency operations are becoming more frequent, with bleeding being the most common indication. Splenic lacerations requiring splenectomy in patients undergoing vagotomy occurred in 3.1 percent of the study population during the 15 year study. The overall mortality rate for elective operations was 1.5 percent and for emergency operations, 17.2 percent. The incidence of acute duodenal ulcer perforation increased during this 15 year study. Duodenal ulcer operations have changed in number and in type as the manifestations of the disease have become altered by trends that began in the mid 1950s and became exaggerated by more effective ulcer therapy.

Surgical treatment of peptic ulcer disease before and after introduction of H2 blockers.

This retrospective study was undertaken to determine if the advent of H2 blockers has altered the surgical treatment and outcome of patients with peptic ulcer disease (PUD). The records of patients having surgery for PUD at Butterworth Hospital, Grand Rapids, Michigan, from 1971-73 (Group 1) and 1981-83 (Group 2) were reviewed. Data recorded included patient and disease characteristics, surgical procedures, morbidity, and mortality. There was a significant difference in mean age: 54 years in Group 1 and 60 years in Group 2. Group 2 had a higher incidence of concomitant medical illnesses. Indications for operation were predominantly of an emergent nature in Group 2, with a marked decline in elective surgeries from 75 per cent to 55 per cent. There was a 15 per cent incidence of nonsurgical complications in Group 2, as opposed to 9 per cent in Group 1. This study demonstrates that the use of H2 blockers and changes in patient characteristics have altered the surgical treatment and outcome of patients with PUD.

[Vagotomy in the surgery of perforated pyloroduodenal ulcer]. / Vagotomiia v khirurgii probodnykh piloroduodenal'nykh iazv.

Under analysis are results of the surgical treatment of 300 patients with perforating pyloroduodenal ulcers. The correct selection of patients for the operation gives best nearest and especially long-term results of vagotomy with antrum resection. The amount of recurrences after a simple suturing of the ulcer in 164 patients was 50%, while after vagotomy with/without various draining operations it was 3.7%. Postoperative lethality after vagotomy was not great, long-term results being considerably better than after the operations of simple suturing the ulcer.

A thousand operations for ulcer disease.

A retrospective study of 1068 patients who had operations for peptic ulcer disease in the 12-year period from January 1, 1974, to January 1, 1986, permits these conclusions: The number of patients admitted to the Massachusetts General Hospital (MGH) has declined steadily in the years of this study--1974-1986. The average number of patients admitted with a diagnosis of peptic ulcer disease in precimetidine years--1974, 1975, and 1976--and in recent years--1982, 1983, and 1984--shows a decline of 39.3% in admissions. In the same periods, the average number of operations per year has declined from 92 in precimetidine years to an average of 71 (16.5%) recently. The decline has been greatest in patients operated on electively for duodenal ulcer. Operations for massive hemorrhage and acute perforations and the number of deaths have remained nearly constant. The overall mortality rate was 10.3%. The mortality following elective operations for pain was 0.5%; for urgent operations, including those for obstruction, 4.5%, and for bleeding other than massive, 7.5%; and for emergency operations, including those for acute perforation, 20.9%, and for massive hemorrhage, 22.1%. The main causes of death were organ failure (most commonly of the lungs) and sepsis. Early complications were documented 345 times and were followed by reoperation in 84 cases, or 7.4% of the total. Delayed stomal function was noted in 63 cases and required reoperation in 14. It was most common after Roux anastomoses and required operative intervention most commonly after gastric resection, Billroth I (GRBI). Delay was three times as common when vagotomy (V) was added to GR. Early postoperative hemorrhage was a serious complication when it occurred after operations for acute perforations or massive hemorrhage. The incidence was 3.7% after suture of a perforation; after operations for acute massive hemorrhage, it was 4.3% after pyloroplasty and vagotomy, with or without arterial ligation [PV(L)], and 0.3% after GR, with or without arterial ligation [GR(L)]. Late complications led to reoperation in 66 cases (6.2%). The most important were recurrent ulceration and alkaline gastritis. Recurrence rates after a minimum follow-up of 5 years (based on survivors of initial procedures and a second operation, both in the MGH) were 20.5% after suture of a perforation, 6.2% after PV, 2.3% after GRBII, and 0.4% after GRVBII. These figures are lower than expected; incomplete follow-up and improved medical care are factors.(ABSTRACT TRUNCATED AT 400 WORDS)

Mortality and morbidity after anterior lesser curve seromyotomy with posterior truncal vagotomy for duodenal ulcer.

A survey has been performed of the mortality and morbidity of anterior lesser curve seromyotomy with posterior truncal vagotomy in the elective treatment of chronic duodenal ulcer. There was one death in a series of 605 patients due to a myocardial infarction, an operative mortality of 0.16 per cent. There was no case of ischaemic necrosis of the lesser curvature or fundus of the stomach. Eleven patients had symptoms of delayed gastric emptying (1.7 per cent) and seven of these underwent a drainage procedure (1.3 per cent). Postoperative dumping did not occur, significant diarrhoea was present in two patients (0.33 per cent). This operation is relatively simple, quick and extremely safe to perform. It is suggested that the more widespread use of this type of elective surgery for duodenal ulcer might reduce the mortality from the condition.

[Vagotomy for the surgical treatment of severe gastroduodenal hemorrhages]. / Die Vagotomie im Konzept zur chirurgischen Behandlung schwerer gastroduodenaler Blutungen.

24 patients (8 female, 16 male) with severe gastroduodenal haemorrhage were treated by vagotomy; in 17 cases highly selective vagotomy was performed, in 3 case truncal vagotomy + pyloroplasty and in 4 patients vagotomy was combined with excision or purse-string suture of the ulcer. Treatment was effective in 23 patients, without recurrence of haemorrhage. In 19 patients vagotomy not only curbed the bleeding but provided definitive therapy (Visick I-II); 4 patients died (mortality rate 16%).

Late mortality after vagotomy and drainage for duodenal ulcer.

Seven hundred and thirty five patients who underwent elective vagotomy and drainage procedures in one hospital during 1957-67 were followed up until 1 September 1982. At this time 281 were dead compared with an expected 184. This gives a ratio of observed to expected deaths of 1.53 (p less than 0.0001). The most important cause of increased mortality was lung cancer, which accounted for 33 of the excess deaths (observed to expected ratio 3.53). Gastric cancer yielded an observed to expected ratio of 3.3. Other causes of death that were significantly more common than expected were cerebrovascular accident, bronchopneumonia, and colorectal cancer. It is concluded that although gastric cancer occurs more commonly after vagotomy and drainage than in the general population, it is not as important a cause of death as diseases related to smoking.

Long-term results of vagotomy and pyloroplasty in the treatment of gastric ulcer disease.

Two hundred thirteen patients were evaluated to establish the efficacy of vagotomy and pyloroplasty in the treatment of benign gastric ulcer disease. These patients underwent operation between the years 1960 to 1973. Ten patients (5%) were found to have occult gastric malignancies and four of these patients (40%) were cured after resectional therapy. Nineteen patients underwent pyloroplasty without vagotomy, and these patients were ultimately excluded from the study in view of the frequency (26%) of ulcer recurrence. The operative mortality rate was 8.4% overall (1.5% when related to elective operations and 22% of the operative deaths following emergent procedures). Eighty-eight percent of the patients were followed until death or for a minimum of 10 years. Recurrent ulcer disease was confirmed in 11% of the patients. Severe postoperative sequelae were encountered in 3% of the patients for a total failure rate of 14% at 10 years. Recurrences and postoperative sequelae were both more common in women and in those patients who underwent operation for intractability. Vagotomy with pyloroplasty is considered an acceptable alternative operation in the management of patients with benign gastric ulcer disease. It is most applicable in the high-risk patient who requires operative intervention emergently and, in this circumstance, a decreased mortality rate can be demonstrated and ulcer recurrence is unlikely (2%).