Truncal Vagotomy for Peptic Pyloric Stenosis and Assessment of Completeness by Acid Tests

Background: Several types of operations are used for Peptic pyloric stenosis (PPS) which includes Vagotomy with antrectomy or drainage procedures. This study was done primarily to analyze the completeness of Truncal vagotomy (TV) by gastric acid secretion tests. The secondary analyses included demographic; clinical profile and out come of the operation.Methods: From December 27/2004 to June 26/2006; 32 consecutive patients; aged 10 to 65 yearsunderwent trans-abdominal (TV) and Posterior Gastrojejunostomy for PPS at Glen C. Olsenmemorial hospital. TV without mobilizing and encircling the esophagus. Prospectivelongitudinal case serial analysis was done to assess the completeness of TV. Outcome measuresused for assessment were the pre-operative basal acid output (BAO); Post-operative BAO; Postoperativesham feeding acid out put (SAO) and other relevant clinical characteristics.Results: After surgery; the average pre-operative BAO had decreased from 6.07+/-2.7mmol/hour to 0.42+/-0.29mmol/hour. The BAO was decreased by 91.3. Mean peak acid response after TV to SAO was 0.83+/- 0.45mmol/hour. The difference between the peak 15minutes out put of SAO and lowest 15 minutes out put of post-operative BAO did not exceed 0.6mmol in 30/32 patients. This shows that TV was complete in 93.7.There was no operative mortality and clinically significant post-operative complication developed in only three patients.Conclusion: Trans-abdominal TV done without mobilizing and encircling the esophagus wasfound safe and effective means of reducing acid secretion for patients with long standing peptic pyloric stenosis

Severe pancreatico-duodenal injuries: the effectiveness of pyloric exclusion with vagotomy.

The operative management and clinical course of 17 patients treated for severe pancreatico-duodenal injuries from 1983 to 1990 was reviewed. The etiology of these injuries was gunshot wound in 15 patients; stab wound in 1 patient; and a motor vehicle accident in 1 patient. Seven patients presented in shock with a systolic blood pressure of less than 80. At exploration, 57 associated injuries were found in the 17 patients including 16 major vascular injuries. All patients were treated with pyloric exclusion and drainage. Vagotomy was performed in eight patients. None of these 17 patients were felt to have extensive enough damage to require pancreatico-duodenectomy. Two patients died in the immediate postoperative period of severe coagulopathy and two patients died of sepsis. Seven patients had complications related to the pancreatico-duodenal injury. All seven developed pancreatic fistulas; three also had pancreatitis and two developed multiple enterocutaneous fistulas. Systemic complications included pulmonary complications in eight patients and sepsis in five patients, including two patients with abdominal abscesses. Six patients bled in the immediate postoperative period secondary to coagulopathy. Three patients had complications related to pyloric exclusion. One developed afferent loop syndrome necessitating reoperation. The other two had marginal ulcers, which either perforated or bled and required reoperation. Of interest, neither of these two patients had vagotomy initially. The results of this series confirm the effectiveness of pyloric exclusion with vagotomy for severe pancreatico-duodenal injury.

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.

Urine acid output as a test of completeness of vagotomy.

Peak acid output in response to sham feeding and changes in urine acid output 2 and 3 hours after a test meal have been measured in 20 normal volunteers, 17 asymptomatic patients after vagotomy, six patients with recurrent duodenal ulcer after vagotomy and ten normal subjects given a 48-h course of ranitidine, 150 mg 12-hourly. Gastric peak acid output in normal volunteers ranged from 6.9 to 22.1 mmol/h. All asymptomatic patients after vagotomy had a peak acid output less than 7 mmol/h, consistent with complete vagotomy. Five patients with recurrent ulcer had a peak acid output greater than 8 mmol/h, suggesting an incomplete vagotomy. Urine acid output after a test meal, expressed as the change from the basal rate of acid output, was always in a negative direction in normal subjects (fall in acid output = postprandial alkaline tide). This change was abolished in patients with complete vagotomy, in whom urine acid output increased after a meal. In five patients with incomplete vagotomy (and one other with recurrent ulcer and unknown vagal status) the urine acid output changed in a negative direction after a test meal. The relationship of urine acid output to gastric secretion was confirmed by the abolition of the postprandial alkaline tide in normal subjects given ranitidine. The results in patients with incomplete vagotomy did not overlap with those from patients with complete vagotomy. This suggests that this test could be used for the routine postoperative assessment of completeness of vagotomy.

Results of highly selective vagotomy in a non-university teaching hospital.

Clinical and laboratory results are presented of 229 patients treated by highly selective vagotomy for duodenal ulcer in a non-university teaching hospital. Sixty-two per cent of the operations were performed by residents as part of their training. After 1-8 years follow-up (97 per cent complete) there were 22 recurrences (9.6 per cent). The residents had fewer recurrences than the consultants, but their patients follow-up was shorter. The usual Visick grading is presented (1, 2: 83.5 per cent; 3, 4: 16.5 per cent) as well as an additional way of grading described by Visick in 1948 which suggests that 4 per cent appear to be permanent failures. Mortality rate was 0.4 per cent, complications rate was low and side effects were in general of minor importance. Laboratory results are presented showing that the basal acid output (BAO) was reduced permanently by 65 per cent, and the PAO by 50 per cent. In patients with recurrences BAO was not reduced and the PAO was less reduced than in the non-recurrence group. Metabolic parameters did not deteriorate. Basal serum gastrin rose after operation while serum vitamin B12 remained constant with a minimal tendency to decrease.

Long-term results of vagotomy in the light of endoscopy.

In the period 1968 to 1973, 177 patients were vagotomized. Endoscopy had to be performed because of definite symptoms in 37 of these patients on 56 occasions between 1971 and 1979. Vagotomy had been selective in 22, truncal in 15 cases. The intervention, regardless of its type, had failed to give the expected benefit in 21% of the patients, a proportion not inferior to the postresection figures. On the other hand, in 12% it was a recurrence of the ulcer which accounted for the symptoms. This is greatly in excess of the recurrences recorded after gastric resection either of the Billroth I or the Billroth II type. This has been attributed to inadequate technique, unsuitable indication or inappropriate selection of the type of surgery.

[Selective proximal vagotomy with intraoperative monitoring using Burge's test]. / Selektive proximale Vagotomie mit intraoperativer Kontrolle nach Burge.

Only the test by Burge shows an effective evidence among the intraoperative control methods for testing the completeness of section during selective proximal vagotomy. The postoperative results are discussed in this study. 78 patients of 91 could be controlled endoscopically 3 to 60 months postoperatively. The result of the group with the Burge test (n = 38) does not differ essentially from the group without the Burge test (n = 40). However, the Burge test has a didactic importance certainly for surgeons in the training.

Selective proximal vagotomy without drainage in the treatment of duodenal ulcer. The results after a standardization of the surgical technique. A five-year follow-up.

Selective proximal vagotomy without polyoroplasty has been shown to be a difficult operation to perform and some investigator have got a rather high frequency of recurrencies and operative complications. In an attempt to reduce the surgical failures a standardization of the operation has been undertaken. In the present material the long term results of a material operated upon with stardardized technique has been estimated. The operation resulted in a high reduction of the ability to secret acid. 90% of the patients had almost no side effects of the operation and 4.4% got a relapse. The relapses developed in patients with a negative postoperative insulin test. The prognostic value of the insulin test seems therefore doubtful.

[Progress in functional gastric surgery for stomach ulcers]. / Fortschritte in der funktionsgerechten Magenchirurgie beim Ulkusleiden.

Different pathogenetic mechanisms lead to the formation of ulcers in stomach and duodenum. They must be taken into consideration, when selecting operative procedures. In the patient with duodenal ulcer we have with the selective proximal vagotomy a procedure at hand that in effective reduction of the secretion of the stomach and in preservation of the form and function of the stomach fulfills all criteria of a functional gastric surgery. At present in patients with gastric ulcers dominate still methods of resection with the aim of the removal of the ulcer and thus healing. The practicability and effectiveness of non-resecting methods is shown also in this case. But it should be controlled in larger clinical studies.

[The insulin test]. / Insulintest.

Since its introduction through Hollander 30 years ago the interpretation of the value of the insulin test following vagotomy have been discussed. For the individual patient no correlation between the incidence of ulcer recurrence and the result of the insulin test has been found. In addition, the risk of hypoglycemia seems to be too high for diagnostic purposes. Therefore, to evaluate the outcome after vagotomy basal acid output, pentagastrin stimulated acid secretion and endoscopy are emphasized as reliable methods.