[Surgical treatment of perforative gastroduodenal ulcers in elderly and senile patients]. / Khirurgicheskoe lechenie probodnykh gastroduodenal'nykh iazv v pozhilom i starcheskom vozraste.

The work is based on experiences with surgical treatment of 206 elderly and senile patients with perforating gastroduodenal ulcers. In 67.5% of cases the perforations took place in duodenal ulcers, in 16%--in the pyloric canal. The gastric body and antral portion ulcers were perforative more rarely--9.8% and 4.8% respectively. Perforations of the cardial and retrobulbar ulcers were found in 1.9% and 1% respectively. At early terms after operation 67 patients (33.5%) died. After suturing the perforative opening 38 out of 98 patients died (38.8%), after dissection and suturing the ulcers died 7 out of 19 patients, after Oppel-Polikarpov operation died 7 out of 11, after resection of the stomach died 4 out of 6, after truncal vagotomy with pyloroplasty died 11 out of 72 patients (15.3%). The main cause of lethal outcomes is thought to be complications of the coexistent diseases, totally responsible for 46.2% of deaths. Truncal vagotomy with a dissection of the ulcer and pyloroplasty performed in 60-70 year old patients gave the least indices of lethality and early postoperative complications, so the indications to radical organ-saving operations in patients of this age must be wider. This method of treatment for perforative ulcers in patients of 71-80 years of age should be used with restrictions due to not bad long-term results of suturing the ulcers (good and excellent results took place in 53.8% of cases). In patients older than 80 radical operations are not indicated. In such cases the ulcer should be better dissected and sutured, the posterior wall of the organ being examined for a "mirror" ulcer.

[Selective proximal vagotomy with excision of duodenal ulcer]. / Selektivnaia proksimal'naia vagotomiia s issecheniem iazvy dvenadtsatiperstnoi kishki.

257 patients with duodenal ulcer and its complications underwent selective proximal vagotomy in combination with excision of duodenal ulcer without pyloric injury. Lethality rate was 0.78%. Long-term results of the operation by Visick's classification are evaluated as excellent and good in 105 (90.5%) patients, in 9 (7.8%) as satisfactory, in 2 (1.7%) as unsatisfactory. It is emphasized that operation saving the pylorus is optimal in such patients and can be performed almost in all patients irrespective of location of the ulcer, presence and tupe of its complications.

Proximal gastric vagotomy. Comparison between open and laparoscopic methods in the canine model.

OBJECTIVE: The authors compared open and laparoscopic proximal gastric vagotomies for efficacy of acid reduction and preservation of gastric emptying. SUMMARY BACKGROUND DATA: Laparoscopic methods have been used to perform vagotomy in patients with duodenal ulcer; however, no direct comparisons are available of laparoscopic and open surgical procedures regarding acid reduction and gastric emptying. METHODS: Thirty-one consecutive dogs were randomized to open proximal gastric vagotomy (OPGV; n = 11), laparoscopic anterior seromyotomy and posterior truncal vagotomy (ASPTV; n = 10), or laparoscopic proximal gastric vagotomy (LPGV; n = 10). Intraoperative endoscopic Congo red testing assured complete vagotomy. Basal acid output (BAO) and maximal acid output (MAO) during pentagastrin and insulin-induced hypoglycemia were measured with marker dilution techniques, and gastric emptying was assessed with radionuclide-labelled solid and liquid markers before and 5 weeks after operation. RESULTS: Operative time (mean +/- standard error of the mean) for OPGV was shorter compared with ASPTV and LPGV (86 +/- 7 minutes vs. 124 +/- 7 minutes and 115 +/- 7 minutes; p < 0.002). Postoperative BAO did not decrease in any group. Open proximal gastric vagotomy and LPGV, but not ASPTV, decreased MAO (p < 0.05); (after pentagastrin, OPGV from 26.4 +/- 1.7 mEq/hour to 11.3 +/- 0.1 mEq/hour, LPGV from 21.4 +/- 1.0 mEq/hour to 6.4 +/- 0.5 mEq/hour; after insulin-induced hypoglycemia, OPGV from 9.9 +/- 0.5 mEq/hour to 2.2 +/- 0.3 mEq/hour, LPGV from 7.9 +/- 0.5 mEq/hour to 1.9 +/- 0.4 mEq/hour). Gastric emptying of liquids and solids, as quantitated by the time for one half of the marker to empty (T 1/2) and the shape of the emptying curve, were similar before and after all three surgical procedures. CONCLUSIONS: Laparoscopic proximal gastric vagotomy was comparable to OPGV in decreasing stimulated gastric acid production without significantly altering gastric emptying. Anterior seromyotomy and posterior truncal vagotomy was less effective in decreasing MAO and required more operative time. Laparoscopic proximal gastric vagotomy has the potential to become accepted therapy for patients with duodenal ulcer managed presently with OPGV.

Vagotomy and antrectomy revisited.

A retrospective review of 185 patients who underwent truncal vagotomy and antrectomy for duodenal ulcer disease was carried out to determine the mortality and morbidity of the procedure. There were no deaths within 30 days of operation and only one patient died while in the hospital (0.54%). Twenty-one patients (11.4%) suffered early morbidity, 3 of them requiring a second operation. Follow-up was obtained in 83 patients and averaged 13.5 years. According to Visick's classification 75 patients (90.4%) were in class I or II; 5 patients (6%) were in class III and 3 patients (3.6%) in class IV. A recurrent ulcer developed in 2 of the 83 patients. In contrast, after highly selective vagotomy, the literature supports an unacceptable incidence of recurrent ulcer. Therefore, we must not prematurely cast aside vagotomy and antrectomy; it still remains a safe and acceptable procedure for duodenal ulcer disease.

Vagotomia supraselectiva: indicaciones y resultados clinicos / Supraselective vagotomy: indications and clinical results

Se analizaron las historias clinicas de 50 pacientes consecutivos que recibieron vagotomia supraselectiva (VSS) como tratamiento de ulcera duodenal, en el Hospital San Igancio de Bogota entre 1976 y 1984. El 74% corresponde al sexo masculino con promedio de edad de 34.9 anos y 6.2 anos de presentar sintomas ulcerosos. La indicacion mas frecuente fue la intratabilidad en 24 casos: la evolucion postoperatoria fue satisfactoria con una estancia hospitalaria de 6.4 dias sin mortalidad operatoria ni postoperatoria. La sensacion de distension abdominal fue la molestia prosoperatoria mas frecuente, presente en 8 pacientes. El seguimiento se realizo en un lapso de 5 a 14 anos. La clasificacion de Visck muestra 86.6% en los grupos I y II y solo se presentaron 2 (6.6%) recidivas ulcerosas comprobadas. La VSS se considera como una operacion segura y con resultados satisfactorios en el tratamiento de la ulcera duodenal intratable

Survival after vagotomy: results of the Aarhus County Vagotomy Trial.

In order to investigate whether the previously found excess mortality in surgically-treated patients with peptic ulcer might be due partly to the resections employed, a survival analysis was undertaken in 824 patients 8-13 years after different types of vagotomy. These patients had been submitted to selective gastric vagotomy with drainage, selective gastric vagotomy with antrectomy or parietal cell vagotomy with or without drainage for duodenal ulcer, pyloric ulcer, prepyloric ulcer, or combined ulceration during the period from 1972 to 1977. A statistically significant excessive mortality was found for both sexes in the total material compared to the background population. Analysis of the material, subdivided according to the operative methods employed, revealed a significant excess mortality in men treated with selective gastric vagotomy and antrectomy, whereas the mortality rates were slightly and insignificantly raised in the nonantrectomy groups. No significant difference in the mortality could be demonstrated in relation to the site of the ulcers. Analysis of the cause-specific mortality revealed a significantly raised mortality from gastrointestinal diseases, including a significant excessive mortality in the subgroups of benign peptic ulcer and cirrhosis of the liver. Likewise, the death rate from accidents including the subgroup of suicide was significantly increased. The overall mortality from malignancies was insignificantly raised among patients, whereas cancer in the stomach was significantly increased. An increased mortality from cancer in the lungs and pancreas did not reach statistical significance. These findings are in reasonable accordance with other studies. A significantly increased mortality from gastric cancer has been usual, although not a constant finding after gastric resection.(ABSTRACT TRUNCATED AT 250 WORDS)

[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%).

Results of elective surgery for recurrent ulcer.

Ninety-two patients operated on electively for recurrent peptic ulcer during the years 1970-1979 were subjected to follow-up after two to twelve years. Two patients died in connection with the reoperation and a third patient during the follow-up time of complications to the ulcer disease (3%). Postoperative complications developed in nine patients (26%) after resection and in five patients (8%) after vagotomy. Ten of 87 patients, who had the combination of vagotomy and resection as a result of the original and present operation, developed suspected or proven recurrent ulcer (11%) while this occurred in four of seven (57%) who had not had this combination. At the follow-up 54% of the patients were classified as Visick I or II. Most of the patients classified as Visick III or IV were so, not because of recurrent ulcer but because of side-effects like dumping, diarrhoea, and vomiting.

Five-year results of proximal gastric vagotomy.

Between February 1972 and December 1976 100 proximal gastric vagotomies (PGV) were performed on duodenal ulcer patients after failure of conservative treatment. The diagnosis was verified by preoperative barium meal and endoscopy and by peroperative examination. There was no operative mortality. Mean duration of postoperative hospital stay was 9.6 days. The percentual distribution in Visick-grading at the 1-year follow-up was 90% in class I + II, and 10% in class III + IV. The corresponding figures at the 5-year follow-up were 82% and 18%. The mean postoperative basal acid output did not change from one to five years. The reduction in pentagastrin stimulated acid output was unchanged at the 1- and 5-year follow-up. Neither did the mean acid output after insulin stimulation change between one and five years postoperatively. The mean concentration of serum gastrin was raised at one year but decreased to normal at the 5-year follow-up. Ten patients (10%) had ulcer recurrence during follow-up. Seven of these were successfully treated by gastric resection and three by antacids and cimetidine.