Pyloroplasty versus gastrojejunostomy. Results of a double-blind, randomized, controlled trial

Long-term metabolic effects of truncal vagotomy and gastrojejunostomy for chronic duodenal ulcer

In a review of 305 consecutive patients who had undergone truncal vagotomy and gastrojejunostomy for duodenal ulceration 5-15 (mean 10.5) years before, symptomatic and metabolic sequelae were related to a dietary survey in 109 patients. The incidence of post vagotomy symptoms was related to the incidence of weight loss and reduced dietary energy intake. The dietary survey did not show any trends in the incidence of weight loss since operation. Biochemical steatorrhoea occurred in 48% of 96 patients, but this was not related to dietary fat intake, or to weight loss unless diarrhoea was also present. Anaemia was noted in 13% of patients, but the incidence was not related to dietary survey, age, symptoms or post-vagotomy gastric acid output.

Prospective randomized study comparing three surgical techniques for the treatment of gastric outlet obstruction secondary to duodenal ulcer

A prospective randomized clinical trial was performed in order to evaluate the results of three surgical techniques for the treatment of gastric outlet obstruction secondary to duodenal ulcer. Ninety patients with clinical and laboratory evidence of gastric retention were enrolled. After laparotomy, patients underwent either highly selective vagotomy (HSV) + gastrojejunostomy, HSV + Jaboulay gastroduodenostomy, or selective vagotomy (SV) + antrectomy. One patient died after HSV + Jaboulay gastroduodenostomy due to postoperative acute pancreatitis. There were no differences in the postoperative course of the three groups. Patients were followed for a mean of 98 months (range: 30 to 156 months). There was a significantly better result after HSV + gastrojejunostomy than after Jaboulay anastomosis (p < 0.01), but not after SV + antrectomy. Gastric acid reduction was similar in the small group of patients studied. We propose HSV + gastrojejunostomy as the treatment of choice in patients with duodenal ulcer and gastric outlet obstruction.

Prospective controlled vagotomy trial for duodenal ulcer: primary results, sequelae, acid secretion, and recurrence rates two to five years after operation

In a prospective, controlled clinical trial, vagotomies for duodenal, pyloric, and prepyloric ulcers were performed on 259 patients. Eighty-three patients were randomly selected for truncal vagotomy and drainage (TV + D), 93 patients were randomly selected for selective gastric vagotomy and drainage (SV + D) and 83 patients were randomly selected for parietal cell vagotomy without drainage (PCV). This interim report deals with the primary results, reduction in acid secretion, sequelae, and recurrence rates two to five years after the operation. One patient died after the operation. Postoperative complications were evenly distributed between the three operations. No differences in spontaneous acid secretion (BAO), peak acid output after pentagastrin stimulation (PAOP), or peak acid output after insulin stimulation (PAOI) were found. Patients with recurrent ulcers ahd smaller reductions in BAO than patients without ulcer recurrences, although not significantly. Patients with ulcer recurrences after TV + D had, in contrast to ulcer recurrences after SV + D and PCV, a significantly smaller reduction in PAOP than patients without recurrences. The overall recurrence rate was 13%: 10% after TV + D, 14% after SV + D and 16% after PCV. The risk of ulcer recurrence within the first three years, calculated by an actuarial method, was found to be significantly higher after PCV (0.52% per month) than after TV + D (0.32% per month), but not different from SV + D (0.42% per month). In contrast to TV + D and SV + D, no recurrences after PCV occurred after three years--25% of the patients were followed for five years. It is concluded that the trial, at present, does not point to any evident superiority of PCV.

Closure of gastrojejunostomy for the relief of post-vagotomy symptoms

When dumping, diarrhoea or bile vomiting follows vagotomy and gastrojejunostomy, simple closure of the stoma, without alternative drainage, has been performed in 19 patients. Thirteen patients, 5 with truncal, 7 with selective and 1 with proximal gastric vagotomy, have been followed up for 1-6 years. Five were completely relieved of symptoms, 7 improved and there was only 1 complete failure. Bile vomiting was more often relieved than dumping or diarrhoea. The procedure is safe and significant gastric retention does not occur provided that at least one year is allowed to elaspse after the primary operation.

Treatment of severe side effects after vagotomy and gastroenterostomy by closure of gastroenterostomy without pyloroplasty

We describe nine patients who had severe, persistent abdominal pain, vomiting, dumping, or diarrhoea several years after truncal vagotomy and gastroenterostomy had been performed for duodenal ulceration. Each patient was judged to have a bad clinical result (Visick grade 4). There was no evidence of recurrent ulceration in any of the patients, and in each the patency of the pyloric canal was confirmed radiologically or endoscopically. Each patient was treated by simply dismantling the gastroenterostomy without addition for a pyloroplasty. In one patient the surgeon suspected that a vagal trunk might have been left intact, and a revagotomy was performed by the "highly selective" technique. Postoperatively, none of the patients developed gastric retention. Symptomatic improvement occurred in eight patients, and four of them achieved perfect results (Visick grade 1). Side effects are common after vagotomy and gastroenterostomy, and are largely attributable to the presence of the gastroenterostomy stoma. Our results show that the symptoms may be alleviated by closing the gastroenterostomy, without precipitating gastric retention.

Review of elective surgical treatment of chronic duodenal ulcer

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.

Changing trends in the surgical treatment of duodenal ulcer

On the basis of fully or partly controlled clinical trials the long term results of several standard operations for duodenal ulcer have been compared--subtotal gastrectomy, truncal vagotomy and antrectomy, truncal vagotomy and gastro-enterostomy, truncal vagotomy and pyloroplasty, selective vagotomy and pyloroplasty and proximal gastric vagotomy without drainage. Few statistically significant differences emerge but the following observations seems to be justified: (a) Subtotal gastrectomy and vagotomy and antrectomy probably offer better protection against recurrent ulceration than any of the other operations examined, but the greater intrinsic operative risks of these two resection procedures is emphasized. (b) Disturbances of alimentary function occur to a variable extent after all operations but appear to be least troublesome after proximal gastric vagotomy without drainage. In particular this operation is followed by a negligible incidence of diarrhoea compared with truncal vagotomy procedures. (c) On overall (Visick) grading the two resection operations and proximal gastric vagotomy without drainage do better than truncal vagotomy with drainage, proximal gastric vagotomy being specially notable for the relatively small proportion of patients in category 3 after its use. Surgical strategy in the choice of elevtive operation for duodenal ulcer is discussed.

The results of reoperation for bile vomiting following surgery for peptic ulcer

A retrospective study is presented of 91 patients (72 male and 19 female) who underwent remedial surgery in the Gastro–intestinal Unit, Western General Hospital, between 1958 and 1972 for bile vomiting following surgery for peptic ulcer. The mean follow–up period was 5.2 years.

Fifty-eight (63.8 per cent) patients had undergone a previous gastric resection, 26 (28.5 per cent)a vagotomy and drainage operation and 7 (77 per cent)a gastrojejunostomy alone.

At reoperation no abnormality could be found to account for the vomiting in 29 (30.9 per cent)patients, 52 (57.1 per cent) had an obstructed afferent loop, efferent loop or stoma and 6 (6.6 per cent) had acute gastritis only. Twelve (13.2 per cent)patients had a recurrent ulcer. Preoperative barium meal examination and gastroscopy together correcrly indicated the operative findings in 846 per cent of cases.

For bile vomiting following Polya gastrectomy 64–68 per cent of those who had a Roux-en- Y conversion or an isoperistaltic jejunal interposition obtained lasting relief of symptoms, as against 55 per cent of patients who had their Polya anastomosis converted to a Billroth Z type. Where the original operation had been a vagotomy and drainage procedure 71 per cent of those converted to a Polya gastrectomy did well, but conversion to a different type of drainage or refashioning of the existing anastomosis was successful in only 40 per cent.

The results in 28 patients with a concomitant psychoneurosis were not significantly different from those in the rest of the group.