MARCH 15, 1958 RESULTS OF VAGOTOMY AND GASTRO-ENTEROSTOMY MEDIC1LJRNAL 615 reduced to a figLure as low as, or lower than, the best after gastrectomy.We at one time thought that the incidence of changed bowel habit after vagal-nerve section might wveigh in favour of gastrectomy. However, a study of these symptoms after gastrectomy reveals exactly the same problem, although to a somewhat less degree. In trying to assess the place of vagotomy and gastroenterostomy, we do not believe that it is indicated only in certain types of patient, as, for example, in women and elderly men. If it is to be used at all, then in our view it should be used in all cases where surgery is necessary. In the present state of our knowledge, based on this eight-year study, we believe that. given complete nerve-trunk section, vagotomy and gastro-enterostomy is the operation of choice. At one time we thought that a surgeon experienced in this operation could in every case achieve complete nerve-trunk section without the use of a test. Since such a test has been available we have satisfied ourselves that this is not true and that even an experienced surgeon will obtain better results with this help.It will be interesting, in the future, to study the late results of this operation in cases in which complete nerve-trunk section has been proved at operation. Summary 301 cases, of which only 6 are untraced, of duodenal ulceration treated by vagotomy and gastro-enterostomy are reported. All patients have been followed up for at least seven years. The proved recurrence rate was 4.25%, and this in spite of evidence of a high rate of incomplete nerve section. There has been no proved recurrence in this series since an earlier review in 1955.The results of this operation are compared with those of gastrectomy, and it is concluded that vagotomy and gastro-enterostomy is a better operation so long as there is no great increase in the recurrence rate as shown by a long-term study. From The method described here was devised to allow the surgeon to test the completeness of vagotomy before the abdomen was closed. It consists in the application of a simple physiological technique to the human and, as such, was first validated on cats. It has now been applied successfully to patients, and is both safe and reliable. MethodCats.-Cats were anaesthetized with chloralose (80 mg./ kg.). The blood pressure was recorded on a kymograph with a mercury manometer connected to a cannula in the left carotid artery. The intragastric pressure was also recorded on the kymograph, using a water manometer connected through the system, as shown in Fig. 1, to give a better exposure of the lower oesophagus. A largebore cuffed rubber tube was passed by the mouth until its
Rundles (1945), who, in discussing the oesophageal changes, considered that the whole problem was a challenge. Mandelstam and Leiber (1967) concluded that the oesophageal motor dysfunction was a common finding in diabetic neuropathy-gastroenteropathy, and that on occasion it results in dysphagia. In their group 12 had oesophageal dysfunction but only three had symptoms, while their control group had no changes at all.The present study indicated that abnormal oesophageal function was not limited to one group and therefore that the abnormality is not specific or exclusive to the diabetic neuropathy group. The chief finding was an incoordination of the primary peristalsis in the body of the oesophagus. In each group there were cases of sliding hiatal herniae associated with both normal and abnormal sphincteric action and peristalsis. With the exception of the non-diabetic symptomatic group, however, there was no correlation between the clinical picture and the cineradiographic motility studies. Similar findings of oesophageal dysfunction were reported in alcoholic neuropathy and normals (Winship et al., 1968).Furthermore, there is no explanation of the pathogenesis which could account for these changes occurring in all the groups at all ages. Vagal degeneration and myopathy of the oesophageal muscle have been incriminated, but with no absolute proof. Recently it has been considered that diabetic neuropathy is a metabolic defect predominantly affecting fat metabolism within the cell which is associated with hyperplasia of the basement membrane (Bischoff, 1968). This latter investigation was carried out on peripheral nerves, and not on the oesophagus or on the rest of the gastrointestinal tract.The conclusion therefore drawn from the present study is that identical cineradiographic and manometric evidence of oesophageal dysfunction can occur in all four groups investigated and not only in those affected by diabetes, with or without neuropathy. British Medical Yournal, 1967, 4, 311. Mandelstam, P., and Leiber, A. (1967 Journal, 1969, 3, 690-693 Summary: The results of surgical treatment for duodenal ulcer were compared in two groups of patients -51 who had undergone selective vagotomy without drainage and 17 who had had selective vagotomy and pyloroplasty. It is suggested that in the absence of organic pyloric or duodenal stenosis the former method seems both preferable and desirable, since postoperatively dumping does not occur and there is a steady improvement in gastric emptying.
and in 6 (40 per cent) of the patients mentioned with early temporary diarrhoea. This type of diarrhoea occurred as frequently after selective vagotomy as after total vagotomy. The incidence of pyloric stenosis in the whole vagotomy series was 24 per cent and in the pyloroplasty group 23 per cent. The incidence of pyloric stenosis in the 79 pyloroplasty patients showing a noticeable delay in the second week was 28 per cent, suggesting that pyloric stenosis is not a predisposing factor. However, 5 out of the 10 cases with severe delay in Table I did have pyloric stenosis. Hendry (1963) and Williams and Barnes (1966) found that pyloric stenosis did not predispose to gastric stasis after vagotomy. SUMMARYThree cases of acute dilatation of the stomach after vagotomy are described. Ten more cases of THE TECHNIQUE THEconsiderable gastric distension were detected by barium meal. All showed a large amount of residual fluid after starving overnight. It is suggested that a routine vertical film of the abdomen before breakfast to show the presence of residual fluid should be done on rice-eating people between the eighth and ninth day after vagotomy before allowing them to go on to a rice diet because of its hygroscopic properties and bulk. 452BRIT.
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