Clinical Results of Parietal Cell Vagotomy and Selective Vagotomy with Pyloroplasty in the Treatment of Duodenal Ulcer Two-year Follow-up of a Prospective Randomized Study A. F A X ~ NJ., KEWENTER & R. STOCKBR~GGER Dcpt. of Surgery I11 and Dept. of Medicine 11, Sahlgren’s Hospital, University of Gothenburg, Gothenburg, Sweden
Scand J Gastroenterol Downloaded from informahealthcare.com by Queen's University on 12/30/14 For personal use only.
Faxen, A., Kewenter,J. & Stockbriigger,R. Clinical results ofparietal cell vagotomy and selective vagotomy with pyloroplasty in the treatment of duodenal ulcer. Two-year follow-up of a prospective randomized study. Scand. J. Gastroent. 1978, 13, 741-745
Fifty patients were randomized in a consecutive series of parietal cell vagotomy (PCV) and selective vagotomy with pyloroplasty (SV + P) in the treatment of duodenal ulcer. There were no operativedeaths,and the length of the hospital stay and time off from work were the same in both groups. The clinical results were evaluated at 1 and 2 years after operation. Within the first 3 years there were two recurrences after PCV and three after SV + P. The overall clinical result 2 years after surgery did not significantly differ between the two groups; 16/24 after PCV and 17/23 after SV + P classified as excellent results (Visick I). Significantly fewer patients had dumping after PCV (3/23) than after SV + P ( 1 3/22). No patient had diarrhoea postoperatively. It is concluded that parietal cell vagotomy gives less dumping than selective vagotomy with pyloroplasty. It is, however, too early to say whether the overall clinical result in a long-term follow-up favours PCV rather than SV + P. Key-words: Clinical result; diarrhoea; dumping; vagotomy, parietal cell; vagotomy,
selective A. Faxin, M.D., Dept. of Surgery, Centrallasarettet. Box 122, S-431 22 Molndal, Sweden
During reccnt years many reports have shown excellent clinical results following parietal cell vagotomy (PCV) in the surgical treatment of duodenal ulcer (1, 8, 9, 17). However, all that glitters is not gold: there are indications that the incidence of recurrent duodenal ulcer tends to increase with time after PCV ( I , & 18). On the other hand, the preservation of the pylorus in this type of operation may compensate for this possible disadvantage, since it has been suggested that a pylorus-preserving operation may prevent biliary reflux gastritis and dumping ( 1 1). However, the other type of operation in which the vagotomy is strictly confined to the stomach, i.e. selective vagotomy with pyloroplasty (SV + P), has been reported to have a low incidence of recurrent ulceration, although the incidence of postcibal symptoms seems to be rather high (14, 16, 17).
The aim of this investigation was to study the clinical result of PCV and SV + P at regular time intervals in a prospective randomized trial. In order to standardize the surgical technique, the proximal dissection was identical in both groups down to the angulus of the stomach (6). PATIENTS A N D METHODS Fifty patients were randomized in a trial of PCV and SV + P. Both types of operation had been used in the department several years before the trial started. The patients constituted a consecutive elective series and had had at least two ulcers confirmed by gastroscopy or barium meal examination. Apart from the ulcer all patients were mentally and physically healthy. Patients over 60 years of age and/or with language difficulties (Swedish) and patients with
742
A . Faxin, J. Kewenter & R . Stockbnigger
Scand J Gastroenterol Downloaded from informahealthcare.com by Queen's University on 12/30/14 For personal use only.
clinical signs of pyloric stenosis were excluded from the trial. No other patients were rejected. Two surgeons performed all surgery. There were 2 0 men and 5 women in each group, and the median age in the PCV group was 4 1 (22-55) years and in the SV + P group 44 (23-56) years. Operative technique and randomization After the laparotomy incision (Amdrup) (2) the pyloric region was examined and a decision made that either type of operation could be performed. Parietal cell vagotomy was performed by the technique described by Amdrup & Jensen without pH measurements (3). The lower 5-6 cm of the oesophagus were skeletonized. The distal dissection was brought down to the crow foot and its proximal branch cut. The bare area of the lesser curvature was not closed. At this stage of the operation the randomization was performed by opening an envelope containing a sign for the choice of either PCV or SV + P. In patients randomized for PCV the abdomen was closed. If the patient was randomized for SV + P, the lesser omentum, including the two nerves of Latarjet, was sectioned and ligated, and a 6- to 7-cm-long Heinecke-Mickulicz pyloroplasty made. Postoperative investigation The patient’s clinical status was evaluated at regular postoperative intervals by a gastroenterologist, who was unaware of which type of operation had been performed. Patients were classified according to Visick (overall result) ( 2 l), Meurling (dumping) (1 9) and Johnston et al. (bowel habits) (1 3) on each examination made after 6 months, 1 year, and 2 years postoperatively. Visick I: an excellent result, the patient was in good general condition and with no symptoms from the gastrointestinal tract. Visick ZZ: a good result, but with occasional epigastric discomfort and/or mild dumping symptoms. These symptoms were easily controlled by reducing the size of the meal or by avoiding some sort of food. Visick ZZZ: the same as Visick 11, but the patient could not control the effects described in that group. The patient had benefited from the operation and had no residual ulcer symptoms.
Visick ZV: a poor result, including patients with recurrent ulcers. The patient did not benefit from the operation and/or had severe side effects (2 1). The evaluation of the severity of dumping symptoms was made according to a modification of Meurling’s classification (4, 19). Grade pc 0: no postcibal symptoms. Gradepc: definiie postcibal symptoms. Grade pc was divided into three groups :mild (pc l), moderate (pc 2) and severe (pc 3). p c I : mild symptoms. The frequency of distress varied from daily to a few times a month. The patient had to rest for a short time after eating when symptoms occurred. pc 2: moderate postcibal symptoms; the patient had to lie down after meals one or more times a week, distress occurring almost daily. pc 3: severe postcibal symptoms. Distress occurred after practically every meal, and symptoms were so severe that the patient had to lie down at least once a day after eating. The patient’s bowel habits were recorded in detail and compared with the preoperative state, and classified according to Johnston at al. ( 1 3). 1. No change. 2. Improved. Earlier constipation or diarrhoea had changed to a more regular bowel action, at the most twice daily. Motions were normally formed but could be porridgy or soft. 3. Diarrhoea. Some urgency but no incontinence. 4. Urgency. The patient was in danger of being incontinent. The attacks of diarrhoea were so frequent or troublesome that they interfered with the patient’s daily activities. The results of acid secretion and gastric emptying tests in this trial have been reported elsewhere ( 5 , 6 , 7 ). Statistical method The Fourfold Table Test was used in calculating the significances between the two groups.
RESULTS There were no operative deaths. The spleen was removed in three patients due to torsion of the capsule, and one patient developed a small necrosis
Vagotomy in Treatment of Duodenal Ulcer
743
Table I. The overall results 6 months and 1 and 2 years after parietal cell vagotomy and selective vagotomy with pyloroplasty Six months Visick
PCV
SViP
22 2
20 1 2
24
Scand J Gastroenterol Downloaded from informahealthcare.com by Queen's University on 12/30/14 For personal use only.
One year PCV
Two years
SV+P
PCV
SV+P
20 3
16
17
5 2
1
17 5 I 1
1
1
2 1 3
24
24
24
24
23
in the fundus and was reoperated upon, with no further complications. There was no difference in the postoperative hospital stay between the two groups (median 6 (3-1 1) days in the PCV group and 6 (4-1 1) days in the SV + P group). Time off from work was 42 (20-82) days after PCV and 45 (24-2 15) days after SV + P. One patient in each group was lost from the followup 1 year postoperatively. One patient in each group was reoperated upon owing to recurrent duodenal ulcer occurring 1 to 2 years after operation and was therefore not included in Tables 11and 111at 2 years. One further patient in the SV + P group was lost from the follow-up 2 years postoperatively.
patient in the PCV group had a recurrence. The firit patient, who also had a severe biliary reflux gastritis was reoperated upon with antral resection and a Roux-Y reconstruction 13 months after PCV. Three patients in the SV + P group developed recurrent ulcers, one patient 6 months, one 18 months and one patient 2 years after surgery. These patients also had severe biligastritis at the time of recurrence. One of these patients has so far been reoperated upon with an antral resection and Roux-Y.
0verall results (Visick) Satisfactory results (Visick I and 11) were obtained 2 years after surgery in 21 of 24 patients following PCV and 19 of 2 3 following SV + P (Table I). There was no difference as regards the overall results between the two groups of patients.
Recurrent ulcer GastroscQpy and barium meal examination were performed in all patients with clinical symptoms of a recurrent ulcer. One patient in the PCV group devel- Dumping During the first 6 months after SV + P about half oped a recurrent ulcer within the first 2 years, and at a recent follow-up 3 years after operation one more of the patients complained of dumping symptoms
Table 11. Dumping symptoms 6 months and 1 and 2 years after parietal cell vagotomy and selective vagotomy with pyloroplasty. For definition of mild, moderate and severe, see text Six months PCV
No dumping (pc 0) Mild dumping (pc 1) Moderate dumping (pc 2) Severe dumping (pc 3)
17 7
Total
24
One year PCV
SV+P 7 6 8 3
24
.
Two years
SV+P
19
9
3 2
12
24
24
PCV
SV+P
20 3
9 12 1
23
22
2 1
744
A , Faxin, J. Kewenter & R . Stockbegger
Table 111. Bowel habit 6 months and 1 and 2 years after parietal cell vagotomy and selective vagotomy with pyloroplasty -
Six months
No change
Improved Mild diarrhoea Severe diarrhoea
Scand J Gastroenterol Downloaded from informahealthcare.com by Queen's University on 12/30/14 For personal use only.
Total
One year
Two years
PCV
SV+P
PCV
SV+P
PCV
SV+P
11
15
18
17
16
15
I
7
6
1
I
I
24
24
23
22
2 24
24
that made it necessary for them to rest after a meal one or several times a week (Table 11). Six months after surgery there were significantly more patients with dumping (pc 2 and pc 3) after SV + P than after PCV (p < 0.002). However, during the first 2 years there was a marked improvement in the SV + P group, and only one patient had moderate dumping symptoms (pc 2) at the 2-year follow-up. However, 2 years after surgery half of the SV + P patients had dumping symptoms, compared with only three after PCV (p < 0.01). These symptoms were, however, mild and did not markedly interfere with the patients’ daily life. Diarrhoea There was no difference between the two groups. No patient complained of diarrhoea 1 or 2 years after surgery (Table 111). DISCUSSION The results reported here, although randomly allocated, could be criticized because the follow-up is limited to 2 years. However, the tendency for dumping to decrease with time within the first years after surgery is well known (4, 11). Furthermore, the incidence of diarrhoea does not seem to increase with time after surgery ( 13). The incidence of ulcer recurrence cannot be properly evaluated with such a short observation time as 2 years. Greenall et al. (10) found no proved recurrences in 250 patients after PCV, but in the 5-to 8-year follow-up Gohgher et al. (8) found in the same patients 5 proved recurrences in 1 1 7 patients. In previous reports of the clinical results of selective vagotomy, the surgical technique around the
cardia has not been clearly defined (17, 20). This dissection was therefore carried out identically in the two groups in the present study. Time off from work following surgery did not significantly differ between the two groups. Twentythree patients after PCV and 19 after SV + P were in full-time work within 60 days of surgery. In Jordan’s series ( 15) only 34% of the patients after PCV and 23% of patients after vagotomy and antral resection were working full time 2 months after surgery. We do not have any explanation of this difference between Jordan’s and our figures. Four patients were off work more than 5 months after SV + P. They all complained of dumping, nausea and vomiting, and one of these patients developed a recurrent ulcer and has since been reoperated upon. Postoperatively, patients in the PCV group often described epigastric fullness and distension of the stomach after meals, a symptom which disappeared within 2 to 3 months. This symptom is probably caused by a lack of receptive relaxation of the stomach and has previously been described after PCV (8, 12). Although a few patients in the SV + P group complained of similar symptoms, dumping symptoms were the most prominent feature in this group during the first postoperative year (Table 11). These dumping symptoms disappeared or were less pronounced after 1 year in about half of the SV + Poperated patients, but many complained of mild dumping symptoms 2 years after surgery. Whether the patients learned to eat in a different way or whether a real improvement occurred during the first 2 years cannot be evaluated. A higher incidence of dumping after SV + P has previously been found in randomized trials of PCV versus SV + P (1 7, 20).
Scand J Gastroenterol Downloaded from informahealthcare.com by Queen's University on 12/30/14 For personal use only.
Vagotomy in Treatment of Duodenal Ulcer
Besides a recurrent duodenal ulcer the most severe postoperative sequel was gastric stasis, biliary reflux, and gastritis, seen in three patients after SV + P. One of these patients also had recurrent duodenal ulcer and has been reoperated upon. However, any major differences in postoperative symptoms between the two groups of patients have not been found, since the majority of the patients have benefited from the operation. The higher incidence of gastric stasis, recurrent duodenal ulcer, and more severe dumping symptoms in some patients after SV + P may indicate PCV. We found a significantly increased acid secretion during the first postoperative year following PCV but no concurrent increase in acid secretion following SV + P, which might indicate a vagal reinnervation in patients following PCV (7). A further followup of these patients will show whether this increase of acid secretion in the PCV group continues, leading to a possibly higher recurrence rate of duodenal ulcer in the PCV group than in the SV + P-operated patients. ACKNOWLEDGEMENT This study was supported by the Swedish Medical IA) Research Council (project N o B75-17X-557-1 and Goteborgs Lakaresallskap. REFERENCES 1. Amdrup, E., Andersen, D. & Jensen, H.-E. Wid. J. Surg. 1977, I , 19-27 Received 13 April 1978 Accepted 15 May 1978
745
2. Amdrup, E., Clemmesen, T. & Andreassen, J. Amer. J. Dig. Dis. 1967, 12, 351-355 3. Amdrup, E. & Jensen, H.-E. Gastroenterology 1970, 59, 522-527 4. Eldh, J., Kewenter, J., Koch, N. G. & Olson, P. Brit. J. Surg. 1974, 61, 9&93 5. Faxen, A., Alpsten, M., Cederblad, A., Kewenter, J. & Rossander, L. Scand. J. Gastroent. 1978,13, 727733 6. Faxen, A. & Kewenter, J. Scand. J. Gastroent. 1978, 13, in press 7. Faxen, A. & Kewenter, J. Scand. J. Gastroent. 1978, 13, in press 8. Goligher, J. C., Hill, G. L., Kenny, T. E. & Nutter, E. Brit. J. Surg. 1978, 65, 145-151 9. Grassi, G., Orecchia, C., Cantarelli, 1. & Grassi, G. B. Jr. Chir. Gastroent. (Surg. Gastroent.) 1977,II, 5 158 10. Greenall, M. J., Lyndon, P. J., Goligher, J. C. & Johnston, D. Gastroenterology 1975, 68, 14211425 1 1. Humphrey, C. S., Johnston, D., Walker, B. E., Pulvertaft, C. N. & Goligher, J. C.Brit. Med. J., 1972, 785787 12. Johnston, D., Gut 1974, 15, 748-757 13. Johnston, D., Humphrey, C. S., Walker, B. E., Pulvertaft, C. N. & Goligher, J. C.Brit. Med. J. 1972, 788790 14. Jordan, P. H. New Engl. J. Med. 1972,287, 13291337 15. Jordan, P. H. Ann. Surg. 1976, 183, 619-626 16. Kennedy.T.&Connel,A. M.Lancet 1969,899-901 17. Kronborg, 0. & Madsen, P. Gut 1975,16. 268-271 18. LiavBg, I. & Roland, M., Abstracts of Papers X Scand. Conf. on Gastroent. 1975. Scand. J. Gastroent. 1976, 11, Suppl. 38, 60 19. Meurling, S. Acta SOC.Med. upsalien., Suppl. 3, 1953 20. Sawyers, J. L., Herrington, J. L., Jr. & Burney, D. P. Ann. Surg. 1977,186, 510-517 21. Visick, A. H. Lancet 1948, 505-510
Scand J Gastroenterol Downloaded from informahealthcare.com by Queen's University on 12/30/14 For personal use only.
Faxen, A., Kewenter,J. & Stockbriigger,R. Clinical results ofparietal cell vagotomy and selective vagotomy with pyloroplasty in the treatment of duodenal ulcer. Two-year follow-up of a prospective randomized study. Scand. J. Gastroent. 1978, 13, 741-745
Fifty patients were randomized in a consecutive series of parietal cell vagotomy (PCV) and selective vagotomy with pyloroplasty (SV + P) in the treatment of duodenal ulcer. There were no operativedeaths,and the length of the hospital stay and time off from work were the same in both groups. The clinical results were evaluated at 1 and 2 years after operation. Within the first 3 years there were two recurrences after PCV and three after SV + P. The overall clinical result 2 years after surgery did not significantly differ between the two groups; 16/24 after PCV and 17/23 after SV + P classified as excellent results (Visick I). Significantly fewer patients had dumping after PCV (3/23) than after SV + P ( 1 3/22). No patient had diarrhoea postoperatively. It is concluded that parietal cell vagotomy gives less dumping than selective vagotomy with pyloroplasty. It is, however, too early to say whether the overall clinical result in a long-term follow-up favours PCV rather than SV + P. Key-words: Clinical result; diarrhoea; dumping; vagotomy, parietal cell; vagotomy,
selective A. Faxin, M.D., Dept. of Surgery, Centrallasarettet. Box 122, S-431 22 Molndal, Sweden
During reccnt years many reports have shown excellent clinical results following parietal cell vagotomy (PCV) in the surgical treatment of duodenal ulcer (1, 8, 9, 17). However, all that glitters is not gold: there are indications that the incidence of recurrent duodenal ulcer tends to increase with time after PCV ( I , & 18). On the other hand, the preservation of the pylorus in this type of operation may compensate for this possible disadvantage, since it has been suggested that a pylorus-preserving operation may prevent biliary reflux gastritis and dumping ( 1 1). However, the other type of operation in which the vagotomy is strictly confined to the stomach, i.e. selective vagotomy with pyloroplasty (SV + P), has been reported to have a low incidence of recurrent ulceration, although the incidence of postcibal symptoms seems to be rather high (14, 16, 17).
The aim of this investigation was to study the clinical result of PCV and SV + P at regular time intervals in a prospective randomized trial. In order to standardize the surgical technique, the proximal dissection was identical in both groups down to the angulus of the stomach (6). PATIENTS A N D METHODS Fifty patients were randomized in a trial of PCV and SV + P. Both types of operation had been used in the department several years before the trial started. The patients constituted a consecutive elective series and had had at least two ulcers confirmed by gastroscopy or barium meal examination. Apart from the ulcer all patients were mentally and physically healthy. Patients over 60 years of age and/or with language difficulties (Swedish) and patients with
742
A . Faxin, J. Kewenter & R . Stockbnigger
Scand J Gastroenterol Downloaded from informahealthcare.com by Queen's University on 12/30/14 For personal use only.
clinical signs of pyloric stenosis were excluded from the trial. No other patients were rejected. Two surgeons performed all surgery. There were 2 0 men and 5 women in each group, and the median age in the PCV group was 4 1 (22-55) years and in the SV + P group 44 (23-56) years. Operative technique and randomization After the laparotomy incision (Amdrup) (2) the pyloric region was examined and a decision made that either type of operation could be performed. Parietal cell vagotomy was performed by the technique described by Amdrup & Jensen without pH measurements (3). The lower 5-6 cm of the oesophagus were skeletonized. The distal dissection was brought down to the crow foot and its proximal branch cut. The bare area of the lesser curvature was not closed. At this stage of the operation the randomization was performed by opening an envelope containing a sign for the choice of either PCV or SV + P. In patients randomized for PCV the abdomen was closed. If the patient was randomized for SV + P, the lesser omentum, including the two nerves of Latarjet, was sectioned and ligated, and a 6- to 7-cm-long Heinecke-Mickulicz pyloroplasty made. Postoperative investigation The patient’s clinical status was evaluated at regular postoperative intervals by a gastroenterologist, who was unaware of which type of operation had been performed. Patients were classified according to Visick (overall result) ( 2 l), Meurling (dumping) (1 9) and Johnston et al. (bowel habits) (1 3) on each examination made after 6 months, 1 year, and 2 years postoperatively. Visick I: an excellent result, the patient was in good general condition and with no symptoms from the gastrointestinal tract. Visick ZZ: a good result, but with occasional epigastric discomfort and/or mild dumping symptoms. These symptoms were easily controlled by reducing the size of the meal or by avoiding some sort of food. Visick ZZZ: the same as Visick 11, but the patient could not control the effects described in that group. The patient had benefited from the operation and had no residual ulcer symptoms.
Visick ZV: a poor result, including patients with recurrent ulcers. The patient did not benefit from the operation and/or had severe side effects (2 1). The evaluation of the severity of dumping symptoms was made according to a modification of Meurling’s classification (4, 19). Grade pc 0: no postcibal symptoms. Gradepc: definiie postcibal symptoms. Grade pc was divided into three groups :mild (pc l), moderate (pc 2) and severe (pc 3). p c I : mild symptoms. The frequency of distress varied from daily to a few times a month. The patient had to rest for a short time after eating when symptoms occurred. pc 2: moderate postcibal symptoms; the patient had to lie down after meals one or more times a week, distress occurring almost daily. pc 3: severe postcibal symptoms. Distress occurred after practically every meal, and symptoms were so severe that the patient had to lie down at least once a day after eating. The patient’s bowel habits were recorded in detail and compared with the preoperative state, and classified according to Johnston at al. ( 1 3). 1. No change. 2. Improved. Earlier constipation or diarrhoea had changed to a more regular bowel action, at the most twice daily. Motions were normally formed but could be porridgy or soft. 3. Diarrhoea. Some urgency but no incontinence. 4. Urgency. The patient was in danger of being incontinent. The attacks of diarrhoea were so frequent or troublesome that they interfered with the patient’s daily activities. The results of acid secretion and gastric emptying tests in this trial have been reported elsewhere ( 5 , 6 , 7 ). Statistical method The Fourfold Table Test was used in calculating the significances between the two groups.
RESULTS There were no operative deaths. The spleen was removed in three patients due to torsion of the capsule, and one patient developed a small necrosis
Vagotomy in Treatment of Duodenal Ulcer
743
Table I. The overall results 6 months and 1 and 2 years after parietal cell vagotomy and selective vagotomy with pyloroplasty Six months Visick
PCV
SViP
22 2
20 1 2
24
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One year PCV
Two years
SV+P
PCV
SV+P
20 3
16
17
5 2
1
17 5 I 1
1
1
2 1 3
24
24
24
24
23
in the fundus and was reoperated upon, with no further complications. There was no difference in the postoperative hospital stay between the two groups (median 6 (3-1 1) days in the PCV group and 6 (4-1 1) days in the SV + P group). Time off from work was 42 (20-82) days after PCV and 45 (24-2 15) days after SV + P. One patient in each group was lost from the followup 1 year postoperatively. One patient in each group was reoperated upon owing to recurrent duodenal ulcer occurring 1 to 2 years after operation and was therefore not included in Tables 11and 111at 2 years. One further patient in the SV + P group was lost from the follow-up 2 years postoperatively.
patient in the PCV group had a recurrence. The firit patient, who also had a severe biliary reflux gastritis was reoperated upon with antral resection and a Roux-Y reconstruction 13 months after PCV. Three patients in the SV + P group developed recurrent ulcers, one patient 6 months, one 18 months and one patient 2 years after surgery. These patients also had severe biligastritis at the time of recurrence. One of these patients has so far been reoperated upon with an antral resection and Roux-Y.
0verall results (Visick) Satisfactory results (Visick I and 11) were obtained 2 years after surgery in 21 of 24 patients following PCV and 19 of 2 3 following SV + P (Table I). There was no difference as regards the overall results between the two groups of patients.
Recurrent ulcer GastroscQpy and barium meal examination were performed in all patients with clinical symptoms of a recurrent ulcer. One patient in the PCV group devel- Dumping During the first 6 months after SV + P about half oped a recurrent ulcer within the first 2 years, and at a recent follow-up 3 years after operation one more of the patients complained of dumping symptoms
Table 11. Dumping symptoms 6 months and 1 and 2 years after parietal cell vagotomy and selective vagotomy with pyloroplasty. For definition of mild, moderate and severe, see text Six months PCV
No dumping (pc 0) Mild dumping (pc 1) Moderate dumping (pc 2) Severe dumping (pc 3)
17 7
Total
24
One year PCV
SV+P 7 6 8 3
24
.
Two years
SV+P
19
9
3 2
12
24
24
PCV
SV+P
20 3
9 12 1
23
22
2 1
744
A , Faxin, J. Kewenter & R . Stockbegger
Table 111. Bowel habit 6 months and 1 and 2 years after parietal cell vagotomy and selective vagotomy with pyloroplasty -
Six months
No change
Improved Mild diarrhoea Severe diarrhoea
Scand J Gastroenterol Downloaded from informahealthcare.com by Queen's University on 12/30/14 For personal use only.
Total
One year
Two years
PCV
SV+P
PCV
SV+P
PCV
SV+P
11
15
18
17
16
15
I
7
6
1
I
I
24
24
23
22
2 24
24
that made it necessary for them to rest after a meal one or several times a week (Table 11). Six months after surgery there were significantly more patients with dumping (pc 2 and pc 3) after SV + P than after PCV (p < 0.002). However, during the first 2 years there was a marked improvement in the SV + P group, and only one patient had moderate dumping symptoms (pc 2) at the 2-year follow-up. However, 2 years after surgery half of the SV + P patients had dumping symptoms, compared with only three after PCV (p < 0.01). These symptoms were, however, mild and did not markedly interfere with the patients’ daily life. Diarrhoea There was no difference between the two groups. No patient complained of diarrhoea 1 or 2 years after surgery (Table 111). DISCUSSION The results reported here, although randomly allocated, could be criticized because the follow-up is limited to 2 years. However, the tendency for dumping to decrease with time within the first years after surgery is well known (4, 11). Furthermore, the incidence of diarrhoea does not seem to increase with time after surgery ( 13). The incidence of ulcer recurrence cannot be properly evaluated with such a short observation time as 2 years. Greenall et al. (10) found no proved recurrences in 250 patients after PCV, but in the 5-to 8-year follow-up Gohgher et al. (8) found in the same patients 5 proved recurrences in 1 1 7 patients. In previous reports of the clinical results of selective vagotomy, the surgical technique around the
cardia has not been clearly defined (17, 20). This dissection was therefore carried out identically in the two groups in the present study. Time off from work following surgery did not significantly differ between the two groups. Twentythree patients after PCV and 19 after SV + P were in full-time work within 60 days of surgery. In Jordan’s series ( 15) only 34% of the patients after PCV and 23% of patients after vagotomy and antral resection were working full time 2 months after surgery. We do not have any explanation of this difference between Jordan’s and our figures. Four patients were off work more than 5 months after SV + P. They all complained of dumping, nausea and vomiting, and one of these patients developed a recurrent ulcer and has since been reoperated upon. Postoperatively, patients in the PCV group often described epigastric fullness and distension of the stomach after meals, a symptom which disappeared within 2 to 3 months. This symptom is probably caused by a lack of receptive relaxation of the stomach and has previously been described after PCV (8, 12). Although a few patients in the SV + P group complained of similar symptoms, dumping symptoms were the most prominent feature in this group during the first postoperative year (Table 11). These dumping symptoms disappeared or were less pronounced after 1 year in about half of the SV + Poperated patients, but many complained of mild dumping symptoms 2 years after surgery. Whether the patients learned to eat in a different way or whether a real improvement occurred during the first 2 years cannot be evaluated. A higher incidence of dumping after SV + P has previously been found in randomized trials of PCV versus SV + P (1 7, 20).
Scand J Gastroenterol Downloaded from informahealthcare.com by Queen's University on 12/30/14 For personal use only.
Vagotomy in Treatment of Duodenal Ulcer
Besides a recurrent duodenal ulcer the most severe postoperative sequel was gastric stasis, biliary reflux, and gastritis, seen in three patients after SV + P. One of these patients also had recurrent duodenal ulcer and has been reoperated upon. However, any major differences in postoperative symptoms between the two groups of patients have not been found, since the majority of the patients have benefited from the operation. The higher incidence of gastric stasis, recurrent duodenal ulcer, and more severe dumping symptoms in some patients after SV + P may indicate PCV. We found a significantly increased acid secretion during the first postoperative year following PCV but no concurrent increase in acid secretion following SV + P, which might indicate a vagal reinnervation in patients following PCV (7). A further followup of these patients will show whether this increase of acid secretion in the PCV group continues, leading to a possibly higher recurrence rate of duodenal ulcer in the PCV group than in the SV + P-operated patients. ACKNOWLEDGEMENT This study was supported by the Swedish Medical IA) Research Council (project N o B75-17X-557-1 and Goteborgs Lakaresallskap. REFERENCES 1. Amdrup, E., Andersen, D. & Jensen, H.-E. Wid. J. Surg. 1977, I , 19-27 Received 13 April 1978 Accepted 15 May 1978
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2. Amdrup, E., Clemmesen, T. & Andreassen, J. Amer. J. Dig. Dis. 1967, 12, 351-355 3. Amdrup, E. & Jensen, H.-E. Gastroenterology 1970, 59, 522-527 4. Eldh, J., Kewenter, J., Koch, N. G. & Olson, P. Brit. J. Surg. 1974, 61, 9&93 5. Faxen, A., Alpsten, M., Cederblad, A., Kewenter, J. & Rossander, L. Scand. J. Gastroent. 1978,13, 727733 6. Faxen, A. & Kewenter, J. Scand. J. Gastroent. 1978, 13, in press 7. Faxen, A. & Kewenter, J. Scand. J. Gastroent. 1978, 13, in press 8. Goligher, J. C., Hill, G. L., Kenny, T. E. & Nutter, E. Brit. J. Surg. 1978, 65, 145-151 9. Grassi, G., Orecchia, C., Cantarelli, 1. & Grassi, G. B. Jr. Chir. Gastroent. (Surg. Gastroent.) 1977,II, 5 158 10. Greenall, M. J., Lyndon, P. J., Goligher, J. C. & Johnston, D. Gastroenterology 1975, 68, 14211425 1 1. Humphrey, C. S., Johnston, D., Walker, B. E., Pulvertaft, C. N. & Goligher, J. C.Brit. Med. J., 1972, 785787 12. Johnston, D., Gut 1974, 15, 748-757 13. Johnston, D., Humphrey, C. S., Walker, B. E., Pulvertaft, C. N. & Goligher, J. C.Brit. Med. J. 1972, 788790 14. Jordan, P. H. New Engl. J. Med. 1972,287, 13291337 15. Jordan, P. H. Ann. Surg. 1976, 183, 619-626 16. Kennedy.T.&Connel,A. M.Lancet 1969,899-901 17. Kronborg, 0. & Madsen, P. Gut 1975,16. 268-271 18. LiavBg, I. & Roland, M., Abstracts of Papers X Scand. Conf. on Gastroent. 1975. Scand. J. Gastroent. 1976, 11, Suppl. 38, 60 19. Meurling, S. Acta SOC.Med. upsalien., Suppl. 3, 1953 20. Sawyers, J. L., Herrington, J. L., Jr. & Burney, D. P. Ann. Surg. 1977,186, 510-517 21. Visick, A. H. Lancet 1948, 505-510
