The combination of proximal gastric vagotomy with a rotational posterior gastropexy for duodenal ulcer

Abstract

(Fuber et al., 1975) We have now applied Maybury's criterion (Maybury et al., 1977) Patients and methodsBetween September 1971 and February 1977, 98 duodenal ulcerpatients had either a proximal gastric vagotomy (46 cases) or a proximal gastric vagotomy combined with a rotational posterior gastropexy (52 cases). Randomization was not carried out because 28 patients with grade 3 oesophageal reflux symptoms had a PGV and gastropexy while only 5 such cases had a PGV alone. Also the PGV series was started 5 months earlier than the PGV and gastropexy series. However, the two groups matched well in respect of age, sex, weight and symptoms.Despite non-randomization, we think the results of the two operations can be fairly compared. It might be argued that the first 10 or so operations constituted a 'learning period' during which vagotomy might be expected to be incomplete. In fact, on insulin testing at 1 year or more postoperatively, only 1 of the first 9 PGV patients (completed before the PGV and gastropexy series was started) was Faber positive (Faber et al., 1975). This compares with 9 Faber positives out of a total of 31 tests carried out in males after PGV. If the runs test for randomness is applied to the Faber positives they are found to be evenly scattered through the group of male PGV insulin tests. Similarly, the runs test shows an even scatter of Maybury positives (Maybury et al., 1977) through the whole group of insulin tests carried out after both PGV and PGV and gastropexy in both males and females. In this respect the series is not non-random.One of us (D. M. H.), who carried out most of the operations, was taught the technique of highly selective vagotomy (HSV) or proximal gastric vagotomy by Professor David Johnston before commencing this work. By this procedure the body, fundus, cardia and lower 4-5 cm of oesophagus are denervated, preserving the nerves of Latarjet to the antrum up to 6-7 crn from the pylorus.In PGV and rotational posterior gastropexy the raw areas that have been dissected in PGV are rotated away from each other by suturing the strong sling fibres of Willis at midanterior gastro-oesophageal junction level to the tough pre-aortic fascia. Two or three good sutures leave the oesophagus under slight tension with the fundus rolled up over its front. At this stage a no. 38-40 stomach tube should pass from the oesophagus into the stomach without let o r hindrance. With the large tube in place the anterior fundoplication (which has formed automatically if the pre-aortic fascia sutures have been correctly inserted) is fixed in place by two to three more sutures between the anterior stomach wall and the oesophagus. The gastro-oesophageal fat pad must be excised as the first step after completion of PGV in order to demonstrate the sling fibres of Willis. This procedure produces an intraabdominal segment of oesophagus witha flapvalve at the gastrooesophageal junction. It also separates nerve twigs (cut during PGV) by traction and rotation at gastro-oesophageal level and rotation at lesser cu...