Truncal Vagotomy and Drainage for Chronic Duodenal Ulcer Disease: A Controlled Trial

Kennedy, Frank P.; MacKay, C; Bedi, B.S.; Kay, A. W.

doi:10.1136/bmj.2.5858.71

Cited by 45 publications

(5 citation statements)

References 6 publications

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“…On the other hand, such duodenoplasties, when carried out in the presence of oedema and fibrosis, could be both difficult to perform and not devoid of the risk of duodenal fistulation. Finally, it should be mentioned that, even after vagotomy with a drainage procedure, gastric emptying is by no means invariably satisfactory (Kennedy et al, 1973). The findings of poor gastric emptying in 9% of patients after TV + D in our series may be unrepresentative, but there is no doubt that gastric retention can occur after both pyloroplasty and gastrojejunostomy, the latter procedure particularly being associated with a wide variety of potential mechanical complications, such as kinking of the loop, retrograde intussusception, and excessive reflux of bile into the stomach.…”

Section: Discussionmentioning

confidence: 99%

Highly selective vagotomy plus dilatation of the stenosis compared with truncal vagotomy and drainage in the treatment of pyloric stenosis secondary to duodenal ulceration.

McMahon¹,

Greenall²,

Johnston³

et al. 1976

Gut

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SUMMARY Twenty-three consecutive patients with duodenal ulceration complicated by pyloric stenosis who came under the care of one surgeon were treated by highly selective vagotomy (HSV) combined with digital dilatation ofthe stenosis through a gastrotomy. No form of drainage procedure was used. Thus the antral 'mill' and the pyloric sphincter were left intact. Since the stenosis is usually distal to the pylorus rather than truly pyloric such dilatation does not damage the pyloric ring, although it may on occasion lead to perforation of the first part of the duodenum. The subsequent progress of these patients was compared with that of a similar, consecutive series of 23 patients with pyloric stenosis who were treated by truncal vagotomy with a drainage procedure by other surgeons on the same surgical unit. Patients were followed up for between four months and five years. The clinical assessment was carried out in 'blind' fashion at a special gastric follow-up clinic. No evidence of recurrent ulceration was found in either group of patients. Two patients from each group subsequently came to reoperation for the relief of gastric stasis. Twenty-two of the 23 patients (96%) who had undergone HSV plus dilatation eventually achieved a good-to-excellent clinical result (Visick grades 1 + 2), whereas only 17 of the 23 patients (74 %) who had undergone truncal vagotomy with drainage achieved such a result. The main clinical difference between the two groups was that side effects such as diarrhoea and abdominal pain or discomfort were more common after vagotomy with drainage than after HSV. These results bear witness to the remarkable propulsive powers of the gastric antrum after HSV, which were evidently sufficient to overcome any tendency to re-stenosis in more than 90 % of patients. The 9 % incidence of failure due to re-stenosis could perhaps be avoided if a small duodenoplasty were performed instead of simple digital dilatation. The results support the hypothesis that damage to the antral mill and pyloric sphincter can be avoided in the course of operations for 'pyloric' stenosis secondary to duodenal ulceration. Avoidance of the drainage procedure is of benefit to the patient, just as it is in patients who have duodenal ulceration without stenosis.When pyloric stenosis is secondary to duodenal stenosis develops, the stomach compensates for the ulceration the adjective 'pyloric' is not quite accurate, obstruction at its outlet by means of hypertrophy of because in most patients the actual site of narrow-its muscular wall and by forceful peristalsis in the ing is beyond the pylorus in the first part of the antrum. Eventually, as stenosis becomes increasingly duodenum. This distinction is important, because it severe, the stomach gives up the unequal struggle, means that the pyloric sphincter and the antral mill becoming dilated and atonic. remain undamaged by the fibrosis, oedema, and Although truncal vagotomy with a drainage spasm which combine to create the stenosis. As procedure

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Section: Discussionmentioning

confidence: 99%

Highly selective vagotomy plus dilatation of the stenosis compared with truncal vagotomy and drainage in the treatment of pyloric stenosis secondary to duodenal ulceration.

McMahon¹,

Greenall²,

Johnston³

et al. 1976

Gut

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show abstract

“…A pyloroplasty or gastroenterostomy, after all, is performed merely to permit the vagotomized stomach to empty; but if the stomach empties well without a drainage procedure, why should one be used? Antrectomy greatly reduces the incidence of recurrent ulceration after truncal vagotomy with a drainage procedure (but only when the incidence of incomplete vagotomy is high [40,43,49]). If, however, the incidence of recurrent ulceration after HSV rises little above its present level of 0-6%, the argument in favour of adding an antrectomy to vagotomy would lack cogency.…”

Section: Clinical Results After Hsvmentioning

confidence: 99%

Physiological and Clinical Significance of Highly Selective Vagotomy without a Drainage Procedure

Johnston¹

1974

Digestion

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This is an account of the first 5 ½-years’ experience of highly selective vagotomy (HSV), an operation which confines vagotomy to the parietal cell mass, leaving the gastric antrum innervated and the pyloric sphincter intact. Gastrin levels have been shown to be no higher after HSV than after truncal vagotomy (TV). The long-term reductions in acid output after HSV are approximately equal to the reductions which are found after TV or SV (selective vagotomy), but the response to insulin is greater after HSV than after TV or SV. Gastric emptying of fluids is under better control after HSV than after TV/SV with a drainage procedure (D). The gall bladder is dilated after TV, but not after SV or HSV. Pancreatic enzyme output in response to vagal stimulation is significantly greater after HSV than after TV + D. Faecal fat excretion is significantly less after HSV than after TV/SV+ D. Operative mortality after 400 HSVs was nil. Post-operative gastric stasis was very rare. Dumping and diarrhoea were significantly less common after HSV than after TV/SV + D: other side effects were no more common. Despite the presence of the innervated antrum, the incidence of recurrent ulceration after HSV was low. 88% of patients had excellent clinical results 2–4 years after HSV, compared with only 70% after vagotomy with drainage.

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“…Visick categories I and II contained 71% of the male sample and only 58% of the female group [7]. Kennedy, Kay, et al;Glasgow H (1973) Between 1965 and 1971 a controlled trial was conducted in 547 patients comparing truncal vagotomy with gastrojejunostomy to truncal vagotomy with Heineke-Mikulicz pyloroplasty [8]. All patients had duodenal ulcers and no emergency cases were included.…”

Section: Leeds-york Trial (1964 and 1968)mentioning

confidence: 99%

Review of elective surgical treatment of chronic duodenal ulcer

1977

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This article is a review of 20 clinical trials of various forms of elective surgical treatment of chronic duodenal ulcer conducted between 1964 and 1975, some of them prospective and others retrospective in nature. Comparisons have been made of the results following truncal vagotomy with drainage, truncal vagotomy with antrectomy, and partial gastrectomy. Additionally, selective vagotomy and truncal vagotomy have been compared in some studies and various forms of drainage, such as pyloroplasty and gastrojejunostomy, have been compared in others. In general, the results of all current forms of elective surgery for chronic duodenal ulcer have been very good, and the differences among the effects of the various procedures have been small. There have been no significant differences in the mortality rates associated with the several operations when they have been performed electively. The rate of ulcer recurrence and incidence of diarrhea have been somewhat higher after truncal vagotomy with drainage, whereas the frequency of dumping and amount of weight loss have been somewhat greater after all forms of gastric resection. Selective vagotomy appears to be associated with less frequent and severe diarrhea than does truncal vagotomy. There have been no apparent differences in the results of the various drainage procedure that have been combined with vagotomy. Highly selective vagotomy without drainage, the most recent operation for duodenal ulcer, has resulted in the lowest incidence of post-operative side effects of any surgical procedure in current use. However, the frequency of ulcer recurrence after this therapeutic measure remains to be determined by long-term studies.

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Truncal Vagotomy and Drainage for Chronic Duodenal Ulcer Disease: A Controlled Trial

Cited by 45 publications

References 6 publications

Highly selective vagotomy plus dilatation of the stenosis compared with truncal vagotomy and drainage in the treatment of pyloric stenosis secondary to duodenal ulceration.

Highly selective vagotomy plus dilatation of the stenosis compared with truncal vagotomy and drainage in the treatment of pyloric stenosis secondary to duodenal ulceration.

Physiological and Clinical Significance of Highly Selective Vagotomy without a Drainage Procedure

Review of elective surgical treatment of chronic duodenal ulcer

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