Br. J. Surg. 1990, Vol. 77, September, 1007-1 009
Anterior lesser curve seromyotomy and posterior truncal vagotomy versus truncal vagotomy and pyloroplasty in the treatment of chronic duodenal ulcer
T. V. Taylor*, J. P. Lythgoef, J. B. McFarlandf, 1. T. Gilmoref, P. E. Thomas* and G. H. Ferguson* Manchester Royal Infirmary*, Royal Preston Hospital? and The Royal Liverpool Hospital$, UK Correspondence to: Mr T. V. Taylor, Department of Surgery, Manchester Royal Infirmary, Manchester MI 3 9WL, UK
In a prospective randomized controlled clinical trial, anterior lesser curve seromyotomy with posterior truncal vagotomy ( A M P T , n = 77) has been compared with truncal vagotomy and pyloroplasty ( T V P , n = 69) in 146patients with chronic duodenal ulcer with a mean duration of symptoms of 7 years. The mean follow-up time was 4.5 years with a range of 2-7 years. One elderly patient died from a myocardial infarction in the T V P group. Acid secretory inhibition in response to insulin and pentagastrin stimuli was equal in both groups, indicating a similar degree of vagal denervation. Recurrent ulcers were more common after A M P T (five) than T V P (two) (P=0.29, n.s.). Dumping and diarrhoea were signijkantly commoner (P< 0.001) after TVP, with 31 instances as opposed to eight with A M P T . The mean operating time was increased by 6 min when A M P T was performed rather than TVP. The results of this study have shown that A M P T is associated with a lower incidence of dumping and diarrhoea and achieves better overall Visick grading. However, continued monitoring is required to assess the long-term incidence of recurrent ulceration after this procedure. Keywords: Anterior lesser curve seromyotomy with posterior truncal vagotomy, truncal vagotomy and pyloroplasty, acid output, dumping, diarrhoea, recurrent ulceration
Although the number of elective operations performed for duodenal ulcer has declined in recent years, there has been no reduction in the number of major ulcer haemorrhages or perforations; indeed, the mortality rate from duodenal ulcer is increasing, particularly in the elderly'. Elective peptic ulcer surgery has been affected not only by the availability of the H,-receptor antagonists but also by concern relating t o the side-effects of truncal vagotomy' a n d the high rates of recurrence after highly selective vagotomy3. In 1979, anterior lesser curve seromyotomy a n d posterior truncal vagotomy (AMPT) was introduced as an alternative form of pyloruspreserving vagotomy4. We have now undertaken a randomized controlled comparison of the results of this operation a n d those of truncal vagotomy a n d pyloroplasty (TVP) over a 7-year period.
Patients and methods One-hundred and forty-six patients with endoscopically proven chronic duodenal ulcer were selected for elective surgical treatment on the grounds of repeated severe symptoms during, or following, courses of H,-receptors antagonists. Patients were randomized to undergo either TVP or AMPT. All operations were performed by one of the authors or a senior registrar. Once the surgeon judged the case to be suitable, an envelope was opened to ascribe randomization by a system of random numbers. Significant pyloric stenosis, as judged by symptoms of gastric stasis and/or the presence of a tight pylorus at operation, was regarded as an exclusion factor. The trial took place in three centres: the Manchester Royal Informary (75 cases), the Royal Preston Hospital (50cases) and the Royal Liverpool Hospital (21 cases). Ethical committee approval for the study and informed consent were obtained. Patients were prospectively assessed concerning the duration and clinical features of their chronic ulcer disease and any history of bleeding or perforation. The duration of H,-receptor antagonist therapy was noted, as were smoking and drinking habits.
0007-1323/90/091007-03
0 1990 Butterworth-Heinemann
Ltd
Routinely, in two centres, gastric acid secretory function tests were performed both before and 2-3 months after surgery (90 patients). Such assessments were performed in response to both 0.2 units/kg intravenous insulin and 6 pg/kg subcutaneous pentagastrin stimulation. In Liverpool, a standardized test meal containing 99"Tc-labelled bran in 100 g ReadyBrek" was utilized. Two egg sandwiches and a cup of tea brought the volume of the test meal up to 4001111 and calorific content to 475 calories. Emptying was assessed postprandially with the patient seated in front of a y-camera computer system5. The duration of the operation and hospital stay, together with operative complications, were recorded on a proforma used by all centres and patients were assessed by participatingconsultants at 6 months, 1 year, and thereafter annually, according to a modified Visick system of grading6. Endoscopy was not routinely performed at follow-up but was undertaken in any patient in whom symptoms were suggestive of recurrent peptic ulceration. Seventy-seven patients were allocated to AMPT and 69 patients to TVP. There were 115 men and 31 women in the study, with no significant difference in their distribution between the two operations. Of the women, 14 underwent AMPT and 17 underwent TVP. For the whole group, the mean(s.d.) ages were 45(13) years in the AMPT group and 45(15) years in the TVP group. The median duration of symptoms was 8.0 years in patients undergoing AMPT and 6.0 years in those undergoing TVP (P = 0.05). There was a previous history of bleeding in 13 patients in the AMPT group and seven in the TVP group. Perforation had occurred previously in four and eight patients in the two groups respectively. At the time of performing AMPT four patients underwent cholecystectomy, three had antireflux procedures and one had a splenectomy. One patient underwent both cholecystectomy and an antireflux procedure at the same time as TVP. The median duration of H,-receptor antagonist therapy was 2.8 years and 2.5 years in the AMPT and TVP groups respectively (P>0.05).The mean(s.d.) duration of follow-up was 45(1.4) years after AMPT and 4.3(13) years after TVP (n.s.); the range of follow-up was 2-7 years. Non-parametric analysis was carried out using the Mann-Whitney Li test; clinical grades were compared using the ,yz test.
1007
Surgery for chronic duodenal ulcer: T. V. Taylor et al.
Table 1 Coniparison ofncid srcreiory darer afier A M P T und T V P Median acid output (mmol/h) AMPT Before operation Basal acid output Insulin (0.2 unitsikg i.v.) induced peak acid output Pentagastrin ( 6 pg/kg s.c.) induced peak acid output After operation Basal acid output Insulin (0.2 unitsikg i.v.) induced peak acid output Pentagastrin ( 6 pg/kg s.c.) induced peak acid output
TVP
P*
2.3
2.3
18.0
16.8
> 0.05 > 0.05
30.4
22.4
> 0.05
1.6 2.08
> 0.05
2.5
11.5
9.78
>0.05
1.4
>0.05
AMPT, anterior lesser curve seromyotomy with posterior truncal vagotomy; TVP, truncal vagotomy and pyloroplasty: i.v.. intravenous; s.c., subcutaneous; * Mann-Whitney U test
Results There was one postoperative death which followed TVP in a 69-year-old man who developed congestive cardiac failure and pneumonia. Preoperative results of acid secretion and stimulated acid output in response to intravenous insulin (0.2 units/kg) and subcutaneous pentagastrin (0.6 pg/kg) between the two operative groups are shown in Table I . Both procedures resulted in a similar percentage reduction in acid output in response to insulin administration, namely 87 per cent after AMPT and 89 per cent after TVP. The mean(s.d.) durations of operation were 53(10)min for AMPT and 47(10) min for TVP ( P =0.2, Mann-Whitney U test). The mean(s.d.) lengths of postoperative stay were also similar, namely 7.1 (1.7)days after AMPT and 7.8(2.3)days after TVP. Distension, a sensation of abdominal swelling or bloating, diarrhoea and dumping were all more common after TVP, with at least one of these problems affecting 31 patients after TVP as opposed to eight patients with AMPT (x2= 21.3, P
Anterior lesser curve seromyotomy and posterior truncal vagotomy versus truncal vagotomy and pyloroplasty in the treatment of chronic duodenal ulcer
T. V. Taylor*, J. P. Lythgoef, J. B. McFarlandf, 1. T. Gilmoref, P. E. Thomas* and G. H. Ferguson* Manchester Royal Infirmary*, Royal Preston Hospital? and The Royal Liverpool Hospital$, UK Correspondence to: Mr T. V. Taylor, Department of Surgery, Manchester Royal Infirmary, Manchester MI 3 9WL, UK
In a prospective randomized controlled clinical trial, anterior lesser curve seromyotomy with posterior truncal vagotomy ( A M P T , n = 77) has been compared with truncal vagotomy and pyloroplasty ( T V P , n = 69) in 146patients with chronic duodenal ulcer with a mean duration of symptoms of 7 years. The mean follow-up time was 4.5 years with a range of 2-7 years. One elderly patient died from a myocardial infarction in the T V P group. Acid secretory inhibition in response to insulin and pentagastrin stimuli was equal in both groups, indicating a similar degree of vagal denervation. Recurrent ulcers were more common after A M P T (five) than T V P (two) (P=0.29, n.s.). Dumping and diarrhoea were signijkantly commoner (P< 0.001) after TVP, with 31 instances as opposed to eight with A M P T . The mean operating time was increased by 6 min when A M P T was performed rather than TVP. The results of this study have shown that A M P T is associated with a lower incidence of dumping and diarrhoea and achieves better overall Visick grading. However, continued monitoring is required to assess the long-term incidence of recurrent ulceration after this procedure. Keywords: Anterior lesser curve seromyotomy with posterior truncal vagotomy, truncal vagotomy and pyloroplasty, acid output, dumping, diarrhoea, recurrent ulceration
Although the number of elective operations performed for duodenal ulcer has declined in recent years, there has been no reduction in the number of major ulcer haemorrhages or perforations; indeed, the mortality rate from duodenal ulcer is increasing, particularly in the elderly'. Elective peptic ulcer surgery has been affected not only by the availability of the H,-receptor antagonists but also by concern relating t o the side-effects of truncal vagotomy' a n d the high rates of recurrence after highly selective vagotomy3. In 1979, anterior lesser curve seromyotomy a n d posterior truncal vagotomy (AMPT) was introduced as an alternative form of pyloruspreserving vagotomy4. We have now undertaken a randomized controlled comparison of the results of this operation a n d those of truncal vagotomy a n d pyloroplasty (TVP) over a 7-year period.
Patients and methods One-hundred and forty-six patients with endoscopically proven chronic duodenal ulcer were selected for elective surgical treatment on the grounds of repeated severe symptoms during, or following, courses of H,-receptors antagonists. Patients were randomized to undergo either TVP or AMPT. All operations were performed by one of the authors or a senior registrar. Once the surgeon judged the case to be suitable, an envelope was opened to ascribe randomization by a system of random numbers. Significant pyloric stenosis, as judged by symptoms of gastric stasis and/or the presence of a tight pylorus at operation, was regarded as an exclusion factor. The trial took place in three centres: the Manchester Royal Informary (75 cases), the Royal Preston Hospital (50cases) and the Royal Liverpool Hospital (21 cases). Ethical committee approval for the study and informed consent were obtained. Patients were prospectively assessed concerning the duration and clinical features of their chronic ulcer disease and any history of bleeding or perforation. The duration of H,-receptor antagonist therapy was noted, as were smoking and drinking habits.
0007-1323/90/091007-03
0 1990 Butterworth-Heinemann
Ltd
Routinely, in two centres, gastric acid secretory function tests were performed both before and 2-3 months after surgery (90 patients). Such assessments were performed in response to both 0.2 units/kg intravenous insulin and 6 pg/kg subcutaneous pentagastrin stimulation. In Liverpool, a standardized test meal containing 99"Tc-labelled bran in 100 g ReadyBrek" was utilized. Two egg sandwiches and a cup of tea brought the volume of the test meal up to 4001111 and calorific content to 475 calories. Emptying was assessed postprandially with the patient seated in front of a y-camera computer system5. The duration of the operation and hospital stay, together with operative complications, were recorded on a proforma used by all centres and patients were assessed by participatingconsultants at 6 months, 1 year, and thereafter annually, according to a modified Visick system of grading6. Endoscopy was not routinely performed at follow-up but was undertaken in any patient in whom symptoms were suggestive of recurrent peptic ulceration. Seventy-seven patients were allocated to AMPT and 69 patients to TVP. There were 115 men and 31 women in the study, with no significant difference in their distribution between the two operations. Of the women, 14 underwent AMPT and 17 underwent TVP. For the whole group, the mean(s.d.) ages were 45(13) years in the AMPT group and 45(15) years in the TVP group. The median duration of symptoms was 8.0 years in patients undergoing AMPT and 6.0 years in those undergoing TVP (P = 0.05). There was a previous history of bleeding in 13 patients in the AMPT group and seven in the TVP group. Perforation had occurred previously in four and eight patients in the two groups respectively. At the time of performing AMPT four patients underwent cholecystectomy, three had antireflux procedures and one had a splenectomy. One patient underwent both cholecystectomy and an antireflux procedure at the same time as TVP. The median duration of H,-receptor antagonist therapy was 2.8 years and 2.5 years in the AMPT and TVP groups respectively (P>0.05).The mean(s.d.) duration of follow-up was 45(1.4) years after AMPT and 4.3(13) years after TVP (n.s.); the range of follow-up was 2-7 years. Non-parametric analysis was carried out using the Mann-Whitney Li test; clinical grades were compared using the ,yz test.
1007
Surgery for chronic duodenal ulcer: T. V. Taylor et al.
Table 1 Coniparison ofncid srcreiory darer afier A M P T und T V P Median acid output (mmol/h) AMPT Before operation Basal acid output Insulin (0.2 unitsikg i.v.) induced peak acid output Pentagastrin ( 6 pg/kg s.c.) induced peak acid output After operation Basal acid output Insulin (0.2 unitsikg i.v.) induced peak acid output Pentagastrin ( 6 pg/kg s.c.) induced peak acid output
TVP
P*
2.3
2.3
18.0
16.8
> 0.05 > 0.05
30.4
22.4
> 0.05
1.6 2.08
> 0.05
2.5
11.5
9.78
>0.05
1.4
>0.05
AMPT, anterior lesser curve seromyotomy with posterior truncal vagotomy; TVP, truncal vagotomy and pyloroplasty: i.v.. intravenous; s.c., subcutaneous; * Mann-Whitney U test
Results There was one postoperative death which followed TVP in a 69-year-old man who developed congestive cardiac failure and pneumonia. Preoperative results of acid secretion and stimulated acid output in response to intravenous insulin (0.2 units/kg) and subcutaneous pentagastrin (0.6 pg/kg) between the two operative groups are shown in Table I . Both procedures resulted in a similar percentage reduction in acid output in response to insulin administration, namely 87 per cent after AMPT and 89 per cent after TVP. The mean(s.d.) durations of operation were 53(10)min for AMPT and 47(10) min for TVP ( P =0.2, Mann-Whitney U test). The mean(s.d.) lengths of postoperative stay were also similar, namely 7.1 (1.7)days after AMPT and 7.8(2.3)days after TVP. Distension, a sensation of abdominal swelling or bloating, diarrhoea and dumping were all more common after TVP, with at least one of these problems affecting 31 patients after TVP as opposed to eight patients with AMPT (x2= 21.3, P
