Twenty years after parietal cell vagotomy or selective vagotomy antrectomy for treatment of duodenal ulcer. Final report

Is vagal stimulation or inhibition benefit on the regulation of the stomach brain axis in obesity?

Objective: Possible effects of the vagus inhibition and stimulation on the hypothalamic nuclei, myenteric plexes and the vagus nerve were investigated.Methods: The female rats divided to the inhibition (INH), stimulation (STI) and, sham (SHAM) groups were fed with high fat diet (including 40% of energy from animal fat). After nine weeks, the rats were allowed to recover for 4 weeks in INH group. In STI group, the left vagus nerve stimulated (30 Hz/500 msn/30 sec.) starting 2nd post operative day for 5 minutes during 4 weeks. Healthy female rats used as control (CONT). Then, tissue samples were analyzed by biochemical, histological and stereological methods.Results: The mean number of the neurons in the arcuate nucleus of the INH group was significantly less; but, that is significantly more in the STI group compared to the other groups. The neuronal density of ventromedial nucleus in the STI group was higher; while the density in the INH group was lower than the other groups. In the dorsomedial nucleus, neuron density of the INH group was lower than the other groups. In terms of the myenteric plexus volumes, that of the INH group was lowest. The myelinated axon number in the INH group was significantly highest. The myelin sheath thickness and axon area of the INH group was significantly lower than the other groups.Discussion: The results of the study show that the vagal inhibition is more effective than the vagal stimulation on the weight loss in the obesity.

[Surgical treatment of ulcerative pyloroduodenal stenosis]

AIM

To obtain the most reliable information about surgical treatment of ulcerative pyloroduodenal stenosis based on the methodology of evidence-based medicine.

MATERIAL AND METHODS

Searching platforms were elibrary, Cochrane Library and PubMed database. The probability of major systematic errors in randomized controlled trials (RCTs) was evaluated.

RESULTS

Systematic review included 20 RCTs for the period 1968-2009 with overall sample of 1794 patients. Evaluation of external validity allows to generalize the results of these studies to the entire population of patients with ulcerative pyloroduodenal stenosis. Assessment of internal validity based on the number of systematic errors showed that 7 (35%) of 20 of RCTs corresponded to the highest level of evidence (level 1), 13 (65%) of 20 had systematic errors and were downgraded in the rating (level 1-). Significant heterogeneity of RCTs impedes metaanalysis. Conclusions and practical recommendations for the treatment of ulcerative pyloroduodenal stenosis are formed according to the results of individual RCTs.

CONCLUSION

Selective vagotomy may be performed for functional stenosis. In case of organic stenosis, truncal vagotomy should be combined with drainage surgery (pyloroplasty, gastroenterostomy) or Roux/Billroth-1 antrectomy. Treatment of decompensated stenosis within evidence-based medicine is unclear. We have not identified target researches with evidence level 1 for this form of stenosis.

Function-preserving gastrectomy for gastric cancer in Japan

Surgery used to be the only therapy for gastric cancer, and since its ability to cure gastric cancer was the focus of attention, less attention was paid to function-preserving surgery in gastric cancer, though it was studied for gastroduodenal ulcer. Maki et al developed pylorus-preserving gastrectomy for gastric ulcer in 1967. At the same time, the definition of early gastric cancer (EGC) was being considered, histopathological investigations of EGC were carried out, and the validity of modified surgery was sustained. After the development of H2-blockers, the number of operations for gastroduodenal ulcers decreased, and the number of EGC patients increased simultaneously. As a result, the indications for pylorus-preserving gastrectomy for EGC in the middle third of the stomach extended, and various alterations were added. Since then, many kinds of function-preserving gastrectomies have been performed and studied in other fields of gastric cancer, and proximal gastrectomy, jejunal pouch interposition, segmental gastrectomy, and local resection have been performed. On the other hand, from the overall perspective, it can be said that endoscopic resection, which was launched at almost the same time, is the ultimate function-preserving surgery under the current circumstances. The current function-preserving gastrectomies that are often performed and studied are pylorus-preserving gastrectomy and proximal gastrectomy. The reasons for this are that these procedures that can be performed with systemic lymph node dissection, and they include three important elements: (1) reduction of the extent of gastrectomy; (2) preservation of the pylorus; and (3) preservation of the vagal nerve. In addition, these operations are more likely to be performed with a laparoscopic approach as minimally invasive surgery. Of the above-mentioned three elements, reduction of the extent of gastrectomy is the most important in our view. Therefore, we should try to reduce the extent of gastrectomy if curability of the gastric cancer can still be achieved. However, if we preserve a wider residual stomach in function-preserving gastrectomy, we should pay attention to the development of metachronous gastric cancer.

A relic or still relevant: the narrowing role for vagotomy in the treatment of peptic ulcer disease

BACKGROUND

Given the rise of medical treatment for peptic ulcer disease (PUD), surgical treatment is necessary only in select cases and emergencies. The authors assess the current relevance of surgical vagotomy to treat PUD and its complications.

DATA SOURCES

Although historically significant, selective and highly selective vagotomy is very technically challenging, and highly selective vagotomy has a relatively narrow indication and high recurrence rates. Vagotomy and gastrectomy is associated with significant side effects. Two types of vagotomy remain relevant, within a narrow scope. Truncal vagotomy and pyloroplasty is safe and efficacious through a laparoscopic approach in certain emergent cases. Vagotomy and Roux-en-Y gastrojejunostomy can be used to treat severe PUD refractory to medical management.

CONCLUSIONS

The role of vagotomy in the management of PUD has a rich history but predated pharmacologic control of acid and understanding of the role of Helicobacter pylori in the disease. Thus, the current role of vagotomy is significantly limited. Specifically, the emergent use of truncal vagotomy is warranted for patients who are either resistant or allergic to proton pump inhibitors.

Evaluation and management of patients with recurrent peptic ulcer disease after acid-reducing operations: a systematic review

This systematic review examines the evidence for commonly employed strategies of managing patients with recurrent ulcer disease after acid-reducing operations. Particular attention is given to recent evidence relating Helicobacter pylori (H. pylori ) and nonsteroidal anti-inflammatory drugs (NSAIDs) to ulcer recurrence after operative therapy. MEDLINE word searches of the literature from 1966 to 2001 identified 895 articles that cross-reference the terms "peptic ulcer disease (PUD)," "surgery," and "recurrence." Articles were selected for systematic review of evidence relating incomplete vagotomy, NSAIDs, and H. pylori to postoperative ulcer recurrence and evidence supporting common medical and surgical strategies. The relationship between incomplete vagotomy and recurrent ulcer disease is suggested by randomized controlled trials and well-designed prospective case series. The evidence that NSAID use is an important pathogenic factor in recurrent ulcer disease includes the relationship between NSAIDs and primary PUD, the occurrence of NSAID-induced ulcers in patients taking proton pump inhibitors, and case series demonstrating virulent ulcer disease in patients taking aspirin despite prior acid-reducing operations. The relationship between H. pylori infection and postoperative ulcer recurrence remains uncertain despite multiple controlled trials and well-designed case series that have documented high rates of H. pylori infection in postoperative patients. The initial management of patients with recurrent ulcer disease after acid-reducing operations consists of a protein pump inhibitor or a histamine-2 receptor antagonist and antibiotics directed at H. pylori, if present. Evidence for this regimen includes prospective randomized trials demonstrating the efficacy of cimetidine in healing ulcers after acid-reducing operations and prospective, randomized studies documenting the efficacy of histamine-2 receptor antagonists and protein pump inhibitors in the management of patients with primary PUD. The critical role that H. pylori infection plays in primary PUD and the minimal risks associated with H. pylori eradication strongly support the initiation of antibiotic therapy when H. pylori is present. The principal indication for operative management of recurrent PUD is the occurrence of ulcer complications that cannot be managed by medical or endoscopic means. The operative management of patients with failed acid-reducing operations is based on ulcer recurrence rates and morbidity and mortality rates in randomized and nonrandomized prospective trials of patients with primary PUD and retrospective case series of patients undergoing remedial operative procedures after various failed acid-reducing operations.

Longterm results of esophageal myotomy for achalasia

BACKGROUND

Achalasia is a progressive, noncurable, motor disorder of the esophagus. Myotomy of the distal esophagus is the principal method of providing palliation. A major controversy is the necessity for a complementary antireflux procedure.

STUDY DESIGN

Forty-two patients were studied by clinical history manometrically, roentgenographically, and endoscopically. Transabdominal Heller myotomy is the preferred approach. Nine patients had Nissen fundoplication and parietal cell vagotomy (group 1), and 16 had posterior gastropexy and parietal cell vagotomy (group II). Initially 16 of 17 patients underwent transthoracic Heller myotomy without fundoplication (group III). Twenty-five patients were followed a mean of 10 years (range 5 to 26 years).

RESULTS

One postoperative death was from adult respiratory distress. Results in group I were excellent in five, good in three, and fair in one. The patient with a fair result developed a diverticulum at the myotomy site and significant reflux at 9 years. Results in group II patients were excellent in 2, good in 11, there was 1 operative death, and no followup in 1. Of the 17 patients in group III, 3 had resection of an esophageal diverticulum, and 3 had closure of esophageal perforation caused by pneumatic dilatation. Results in the 13 patients followed were excellent in 6, good in 5, and poor in 2.

CONCLUSIONS

There is no statistical difference in results by chi-square analysis between transthoracic Heller myotomy without fundoplication and transabdominal Heller myotomy with parietal cell vagotomy and Nissen fundoplication or posterior gastropexy.

Abdominal and dyspeptic symptoms in patients with peptic ulcer treated medically or surgically

BACKGROUND

Abdominal and dyspeptic complaints, which are prominent symptoms in patients with peptic ulceration, are commonly reported in the general population. There are few reports of follow-up study of peptic ulcer therapies in which clinical outcome has been compared with symptom reporting in community controls.

METHODS

Three populations of patients with peptic ulcer disease (patients who had elective proximal gastric vagotomy (PGV), those having PGV for emergency indications and those receiving medical treatment with H2-receptor antagonists) were included in a questionnaire survey and compared with a group of randomly selected community controls.

RESULTS

The vagotomized patients reported fewer abdominal complaints (P = 0.0003) and fewer dyspeptic complaints lasting for more than 1 week (P = 0.05) than those treated medically. There was no significant difference between vagotomized patients and community controls in the reporting of abdominal (P = 0.2) or dyspeptic (P = 0.9) complaints.

CONCLUSION

Taking abdominal complaints as the endpoint for former peptic ulcer treatment, surgical treatment with PGV seemed to be superior to therapy with H2-receptor antagonists and produced an almost identical level of complaints to that seen in the community population.

Laparoscopic highly selective vagotomy

Laparoscopic highly selective (anterior and posterior) vagotomy was performed in 11 patients for duodenal ulcer (n = 10) and duodenal ulcer with prepyloric ulcer (n = 1). All patients were endoscoped both pre- and postoperatively. There were no perioperative complications. The average operating time was 3.2+/-0.4 hours and the average hospital stay was 1.7+/-0.2 day (range 1 to 3 days). None of the patients required parenteral narcotics postoperatively. The patients have been followed for 6 months to 5 years after operation. All ulcers healed as demonstrated by endoscopy. There was one recurrence at 9 months in a patient who had a prepyloric ulcer preoperatively. The recurrence was treated successfully with medication. There has been no other long-term morbidity. Laparoscopic highly selective vagotomy is feasible, safe, requires a brief hospital stay, and produces short-term results comparable with open surgery.

Parietal cell vagotomy performed with fundoplication for esophageal reflux

BACKGROUND

Reduction of acid secretion is an important aspect of medical treatment of reflux esophagitis. Truncal vagotomy and drainage procedures used in conjunction with antireflux procedures to reduce acid secretion in patients with gastroesophageal reflux were unsatisfactory. This study reviews the results of parietal cell vagotomy used in conjunction with a 360-degree fundoplication to determine if reduction of acid by this form of vagotomy was beneficial to patients with gastroesophageal reflux.

METHODS

Between March 1973 and May 1993, 94 private and 64 Veterans Administration patients underwent parietal cell vagotomy and Nissen type fundoplication for esophageal reflux. Esophagogastroduodenoscopy (EGD), gastric analysis, cine-esophagogram, and 24-hour esophageal pH and motility studies were performed preoperatively on VA patients. Private patients underwent EGD, cine-esophagogram, and sometimes pH and motility studies. Similar studies were performed postoperatively if the patient permitted. The major technical alteration made during the study was the addition of posterior gastropexy to the operations performed between March 1978 and January 1987. Patients were considered failures if dysphagia and reflux symptoms were moderate but operation not contemplated (Visick III) or symptoms were severe and reoperation had been performed or was contemplated (Visick IV).

RESULTS

There were no operative deaths. There were 25 operative failures; dysphagia contributed to failure in 4, reflux in 11, and dysphagia and reflux in 10 patients. Reoperation was required in 6 patients. There was no statistical difference in acid secretion inhibition for patients with or without postoperative reflux symptoms. The cumulative probability for operative failure was 9.3 +/- SE 4.2% for patients who underwent posterior gastropexy and 22.9 +/- SE 4.6% (P <0.02) for those who did not.

CONCLUSIONS

Parietal cell vagotomy with Nissen fundoplication is a safe operation. The exposure created by PCV protected the vagi from injury. The study design made it impossible to determine whether PCV improved the results of fundoplication but the failure rate was significantly (P <0.02) reduced by the addition of posterior gastropexy. This may have lessened the risk of disintegration of the wrap that might be more likely to occur after PCV.

Minimally invasive surgery of the esophagus and stomach

BACKGROUND

Minimally invasive surgery has assumed an ever-expanding role in gastrointestinal surgery since the introduction of laparoscopic cholecystectomy. This review describes some of the more common minimally invasive procedures of the esophagus and stomach, with particular attention to technique.

DATA SOURCES

A literature review of minimally invasive surgery of the esophagus and stomach was conducted.

CONCLUSIONS

Laparoscopic (and thoracoscopic) approaches for gastroesophageal reflux disease appear to have excellent operative and short-term follow-up results. Long-term follow-up data, however, remain unobtainable for several more years. Limited reports of esophageal cardiomyotomy, paraesophageal hernia repair, and gastric surgery for peptic ulcer disease performed through a minimally invasive approach are encouraging. Experience with resection of esophageal and gastric neoplasia is limited to a few specialized centers. Results should be scrutinized and compared with open operation before proclaiming the benefits of a minimally invasive approach.

A 50-year perspective upon selective gastric vagotomy

BACKGROUND

The occurrence of postvagotomy complications was initially considered an unavoidable but acceptable consequence of duodenal ulcer surgery. Following the description of "selective" vagotomy procedures, however, it became apparent that effective ulcer surgery might be accomplished without unpleasant sequellae.

METHODS

In 1957 the experimental basis for "highly" selective vagotomy (HSV), which preserved antral innervation, was reported. HSV was performed in several European centers between 1960 and 1968, and was widely accepted there. Surgeons in the United States, in contrast, were largely reluctant to use HSV, an operation which had an excessive ulcer recurrence rate compared to vagotomy-antrectomy. More recently, HSV is recognized as a successful operation, due to more complete division of preganglionic gastric vagal nerves ("extended" HSV) and the liberal use of pyloric reconstruction in patients with juxtapyloric ulcers.

RESULTS

HSV is performed with minimal morbidity, with an incidence of recurrent ulcer which is less than 5%. Complications such as dumping, diarrhea, and gastric atony are quite rare.

CONCLUSIONS

HSV is an ideal procedure for most patients with duodenal ulcer. Because most operations for ulcer are performed for urgent or life-threatening problems, the most common operation performed in the United States today is truncal vagotomy combined with pyloroplasty or gastric resection. Earlier operation for chronic ulcer has many potential advantages.

Perforated pyloroduodenal ulcers. Long-term results with omental patch closure and parietal cell vagotomy

OBJECTIVE

The authors evaluated parietal cell vagotomy and omental patch closure as treatment for perforated pyloroduodenal ulcers.

BACKGROUND DATA

Since the beginning of the century, there has been a difference of opinion as to whether perforated pyloroduodenal ulcers are best managed with nonoperative treatment, simple closure, or definitive treatment, i.e., a procedure that handles the emergency problem and simultaneously provides protection against further ulcer disease. The criticism of using definitive treatment at the time of perforation has been that some patients who might not have recurrent ulcer, if a definitive operation was not performed, would be at risk of adverse postoperative sequelae, including death. Parietal cell vagotomy as treatment of intractable duodenal ulcer disease was shown to be almost without complications. The objective of this study was to determine if the operation was equally applicable to perforated pyloroduodenal ulcers.

METHODS

A group of 107 selected patients with perforated pyloroduodenal ulcers underwent definitive treatment by omental patch closure and parietal cell vagotomy. The patients were evaluated prospectively on an annual basis up to 21 years. Gastric analyses were performed on each visit for which the patient gave his/her consent. Patients suspected of a recurrent ulcer were examined endoscopically for verification.

RESULTS

There was one death (0.9%). Ninety-three patients were observed for follow-up for 2 to 21 years. The recurrent ulcer rate by life table analysis was 7.4%. The reoperative rate was 1.9%. Postoperative gastric sequelae were insignificant. All but four patients were graded Visick I or II at the time of their last evaluation.

CONCLUSION

This study confirms that the combination of parietal cell vagotomy and omental patch closure is an excellent choice for treatment of patients with perforated pyloroduodenal ulcers, who, by virtue of their age, fitness, and status of the peritoneal cavity are candidates for definitive surgery. Virtually none of the morbidity that occurs with other forms of definitive treatment is inflicted on patients who might never have needed a definitive operation if simple closure was performed. At the same time, it provides definitive therapy for the larger number of patients who subsequently would have required a second operation for continued ulcer disease if simple closure alone was performed. Whether this operation is performed at the time of perforation should depend on the presence or absence of risk factors, rather than whether the ulcer is acute or chronic.