Clinical and radiological study of vagotomy and gastric drainage in the treatment of pyloric stenosis due to duodenal ulceration

Delayed return of gastric emptying after gastroenterostomy

A retrospective study of patients having gastroenterostomies was undertaken to identify predictive factors for the development of postoperative delayed return of gastric emptying (DRGE). A total of 322 consecutive patients underwent 324 gastroenterostomies; 35 experienced delayed return of gastric emptying. Regression analysis demonstrated preoperative obstruction to be the most significant factor (P less than 0.001). Vagotomy was not an independent variable. Age, sex, size of stoma, anastomotic technique, albumin and experience of the operator were not significant factors. Gastroenterostomy in the presence of 'gastric atony' was likely to produce DRGE. In all, 86 per cent of cases resolved spontaneously. Only one case of DRGE was found to have a mechanical cause. Most patients were supported by parenteral nutrition but, with a knowledge of the identified risk factors, more thought could be given to establishing a route for jejunal feeding at the time of surgery.

Peroperative grading of pyloric stenosis: a long term clinical and radiological follow-up of patients with severe pyloric stenosis treated by highly selective vagotomy and dilatation of the stricture

Highly selective vagotomy (HSV) is now an accepted form of surgery for uncomplicated duodenal ulcer. Highly selective vagotomy and dilatation has been successfully used in some cases of pyloric stenosis, but many would regard severe pyloric stenosis as a contraindication to this procedure. Eleven patients with severe pyloric stenosis, measured objectively at operation, have been treated by HSV and dilatation of the stenosis and reviewed for periods of up to 3 years. The clinical results, immediate and long term, were good in all cases. Barium studies and histopathological findings were slower to return to normal. With intensive preoperative preparation to restore the tone of the dilated gastric muscle and gentle, controlled dilatation of the stricture, HSV in these patients should be as satisfactory as in those patients with uncomplicated duodenal ulcer.

Obstructing duodenal ulcer

The incidence, pathogenesis, symptoms, roentgenographic, and endoscopic findings of patients with gastric outlet obstruction from a chronic duodenal ulcer have been reviewed. In the experience of many surgeons, including myself, vagotomy and an adequate drainage procedure (Finney pyloroplasty, gastrojejunostomy, or gastroduodenostomy) provide excellent decompression of the obstructed stomach. as well as excellent control of the ulcer disease in most patients. Postvagotomy gastric atony has not been a problem.

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

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 of the stenosis through a gastrotomy. No form of drainage procedure was used. Thus the antral "mill" and the pyloric sphineter 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), wheras 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.

Late results of bilateral selective vagotomy and pyloroplasty for duodenal ulcer: 5-9-year follow-up

From July, 1964, to July, 1968, bilateral selective vagotomy and pyloroplasty were performed in 135 patients for duodenal ulcer, without postoperative mortality. Two unrelated deaths occurred during the period of the survey and 2 other patients were lost to follow-up. The remaining 131 patients were followed up for a minimum of 5 years and a maximum of 9 years.

The most frequent symptoms were epigastric fullness, early dumping and mild diarrhoea. Only I case of moderate diarrhoea was observed, and none of severe diarrhoea. Food vomiting, bile vomiting and hypo-glycaemia-like attacks were uncommon. Recurrent duodenal ulcer was proved in 4.6 per cent and highly suspected in 1.5 per cent. Gastric ulcer was proved in 3.1 per cent. Approximately 91 per cent of the patients were classed as having a satisfactory result and 9 per cent were unsatisfactory.

It is concluded that bilateral selective vagotomy is clearly effective in controlling the ulcer diathesis in the long term. In addition, it seems to lessen some of the side-effects of gastric surgery. For these reasons, consideration should be given to its use in the surgical treatment of duodenal ulcer.

Highly selective vagotomy and drainage for duodenal ulcer stenosis

Thirteen cases of duodenal ulcer complicated by stenosis have been subjected to highly selective vagotomy and a gastro-enterostomy, the gastric stoma of which was situated on the greater curvature in order not to interfere with the antral motility. There was no radiological or clinical evidence of postoperative gastric retention.

The evaluation of vagotomy and pyloroplasty in the treatment of duodenal ulcer in Nigerians: clinical and radiological study

Forty-eight patients with duodenal ulceration were treated by vagotomy and the Weinberg type of pyloroplasty. This procedure was modified for 19 patients in the group with duodenal stenosis. Postoperative radiological evaluation indicated satisfactory results in 41 patients. The symptomatically satisfactory rate was good. Diarrhoea was a major residual symptom. Vagotomy and pyloroplasty is advocated for the surgical treatment of duodenal ulceration in Nigerians.

Selective vagotomy and pyloroplasty in the treatment of gastric ulceration: some clinical observations and results

Selective vagotomy and pyloroplasty have been used in 43 patients with gastric ulceration between July, 1964, and January, 1968. Clinical and radiological observations demonstrated that the ulcer usually took 15–20 days to be cured, although in some cases this period was substantially prolonged.

Up to the present recurrence has been observed in 3 patients (7.8 per cent), all of whom showed signs of prolonged antral retention, together with incomplete vagotomy in I case. Pathogenic considerations concerning the possible causes of this recurrence are suggested and discussed.

Functional results are at present very satisfactory in 84.2 per cent of patients, in whom it has once more been observed that the use of selective vagotomy seems to avoid the appearance of serious diarrhoea, which is not unusual after truncal vagotomy.

Preliminary results show that vagotomy and pyloroplasty seem to bring about a cure in cases of gastric ulcer and that these methods offer certain possibilities of cure. However, the appearance of a number of recurrent ulcers obliges us to observe a certain prudence until we have at our disposal more evidence and experience of the method.