Proximal gastric vagotomy, fundoplication, and lesser-curve necrosis.

Abstract

1455microscopically that the degree of dilatation of the pyloric canal used (4 cm) causes any morphological change in the mucosa or the musculature of the wall. On the other hand, clinical, radiological, and endoscopic evidence shows that the intricate mechanism of the antropyloroduodenal channel is not destroyed, as, for example, in pyloroplasty. Bile reflux was not seen clinically, and no patient developed a postoperative gastric ulcer. We believe that patients return to normal feeding earlier and that the incidence of undesirable sequelae is lower after TV and PD compared with patients in whom one of the conventional drainage procedures have been performed. Further study will be required before any real comparison can be made with the results after PGV.Goligher,'1 reporting on a series of 117 patients who underwent PGV and were followed up for five to eight years, recorded a similar overall result in terms of Visick gradingnamely, 75),, in categories I plus II. As compared with vagotomy and drainage he concluded that PGV was followed by less dumping and diarrhoea but did not offer appreciably better overall results. Mackey et al,13 reporting on a series of 115 patients who had been treated by PGV and followed up for one to five years in a district general hospital, recorded a satisfactory result in 9100. Their incidence of recurrent ulceration was 5-1°o after an average interval of two years and that of new gastric ulceration 2 50 after an average of four years.PGV is a technically exacting procedure attended by anxieties related to the vascularity of the lesser curvature of the stomach.'441 By contrast, TV and PD is both safe and economic in terms of time and manpower and complies with Dragstedt's view'6 that "the operation for elective duodenal ulcer surgery must be safe in the hands of the average surgeon using a technique that is acceptably effective." Journal, 1979Journal, , 1, 1455Journal, -1456 Summary and conclusions Out of 400 patients who underwent proximal gastric vagotomy (PGV), three developed lesser-curve necrosis (LCN) leading to perforation within the first seven days. In each case diagnosis was delayed but the patient survived after a second operation. In each an associated Nissen fundoplication had been carried out; we used the combined operation in only 33 patients. Delayed LCN occurred in a patient who had undergone splenectomy at the time of the PGV and in a fifth patient treated elsewhere who had also undergone fundoplication. These findings indicate that early postoperative gastric distension with gas, not readily voided after fundoplication, may aggravate local vascular factors and predispose to LCN. We suggest that PGV combined with fundoplication may be dangerous.

The Effect of Intragastric Pressure on Gastric Blood Flow after Partial Devascularization of the Stomach in Cats

“…[13] described 3 patients where increased IGP, due to proximal gastric vagotomy plus fundoplication, probably was a major factor in the develop ment of lesser curvature necrosis.…”

“…Necrosis or ulcer ation at the lesser curvature have occurred in man in the early postoperative period, and localized ischemia is assumed to bean important factor to these complications [5,6,12,14], It has been demonstrated that the intraluminal gastric pressure (IGP) is elevated after proximal gastric vagotomy both in man and experimental animals [2,11,19,21], Elevation of IGP could worsen an ischemia of the stomach wall induced by devascularization [4,8,13], In the present work we, therefore, studied the effect of IGP changes on tissue blood flow in the stomach with regional ischemia caused by devascularization.…”

Barrett's esophagus: surgical treatments

“…Kennedy et al . reported four cases of necrosis of the lesser curvature of the stomach in patients who had undergone this combined procedure and cautioned against its use 37 . Delayed gastric emptying (DGE) was demonstrated in patients who had undergone HSV and fundoplication, compared to those after fundoplication alone by Jamieson et al , although there were no differences between the two groups in terms of symptomatic outcome 38 .…”

Die Magenwandnekrose nach selektiv-proximaler Vagotomie

“…Hierzu z~ihlen altersbedingte Sklerose [2,17,18,24], Hypertonie [16,19,24], Diabetes [18] und chronische Niereninsuffizienz [16,18,24]. Aus obigen Oberlegungen erhellt, da6 vornehmlich Krankheitsbilder mit Kompromittierung des Gef~il3systems das Risiko einer MWN steigern (Tabelle 1).…”