Annals of the Royal College of Surgeons of England (1976) vol 58
ASPECTS OF TREATMENT*
Duodenoplasty with proximal gastric vagotomy Terence Kennedy MS FRCS Consultant Surgeon and Lecturer in Gastroenterological Surgery, Royal Victoria Hospital and Queen's University, Belfast
Summary To permit proximal gastric vagotomy without drainage in patients with gross duodenal narrowing a simple longitudinal incision, sutured transversely, has been found to be simple and safe. Early follow-up results have been satisfactory. Introduction Much evidence has accumulated of the superiority of proximal gastric vagotomy (highly selective vagotomy) without drainage in the routine treatment of chronic duodenal ulcer",2. Unfortunately this technique has not been generally applicable where there is mechanical obstruction to gastric emptying pyloric stenosis. Johnston' first excluded these cases but later described digital dilatation, though this led to perforation of the duodenal wall in 4 of I 5 dilatations'4. It is well known that 'pyloric' stenosis is, in fact, usually a duodenal stenosis and we have found that the point of narrowing is uisually I .5 cm or more beyond the pyloric ring. Where there is pseudodiverticular formation the narrowing occuirs beyond the pouches. It occurred to uis that in this group of cases a Heineke-Mickulicz 'pyloroplasty' could be performed more distally, leaving the important pyloric ring intact, thus permitting proximal gastric vagotomy without drainage.
through the pylorus may give better evidence. When there is an inadequate lumen a duodenoplasty is required. To facilitate access the second part of the duodenum is first mobilized by Kocher's manoeuvre A longitudinal incision is then made across the stricture and extended for 1-2 cm on either side, but it must not cross the pyloric ring (Fig. i), which is idcntified by the pyloric vein of Mayo and by palpation. In our experience the length of incision has varied between 2 and 6 cm. To avoid haemorrihage we normally make this incision with a cauitery knife, but diathermy can be used. It is generally easiest to open the duodenum distally, in-
Operative technique When the duodenum is exposed and the presence of ulceration or scarring is confirmed an estimate of the adequacy of the outlet must be made. Palpation between index finger and thumb or invagination5 will usually provide the answer, but occasionally the passage of FIG. I The incision is started distally and a large (3o F gauge) nasoga-stric tube down continued proximally through the stricture. *Fellows and Members interested in submitting papers for considerationi with a publication in this series should first wvrite to the Editor.
Xview to
Duodenoplasty with proximal gastric vagotomy
FIG. 2)
denal
After transverse suture achieved.
a
wide duo-
lumen is
a pair of forceps in a retrograde fashion, and ctut down on this instrument. The integrity of the pyloric muscle ring is confirmed and the index finger is gently passed back into the antrum to exclude any pyloric mucosal diaphragm or other narrowing. The incision is then closed transversely using two layers of chromic catgaut; one layer of sutures would probably be perfectlv satisfactory (Fig. 2). The operation is concluded by proximal gastric vagotomy, leaving intact the nerves of Latarjet to the distal 6 cm of antrum, measured from the pyloric ring.
sert
I145
When operation is performed for acute haemorrhage from a chronic duodenal ulcer it is virtually certain that the ulcer will be found on the posterior wall eroding the gastroduodenal artery. It is orthodox to expose the bleeding point through a long pyloroduodenotomy, under-run the vessel, and complete the operation as a truncal vagotomy and pyloroplasty. We have found it simple and satisfactory to limit the exporure to a duodenotomy, close it as a duodenoplasty, and finish the operation as a proximal gastric vagotomy without drainage. Twice when attempting duodenoplasty we found it necessary to transgress the pyloric ring to obtain an adequate lumen. In each case this transgression was limited to 0.5 cm in the hope that at least a part of the control mechanism would be preserved. When this is done it seems advisable to do a proximal gastric vagotomy. Occasional patients with jejunal ulcer following gastrojejunostomy without vagotomy are still seen. In 5 of these patients we have closed the gastrojejunostomy and performed a proximal gastric vagotomy; 3 of these had gross narrowing of the duodenum with longhealed ulceration, which was easily dealt with by duodenoplasty.
Results There have been no deaths or major complications. With a maximum follow-up of 212 years no claims can yet be made for the longterm results. In the early follow-up we have had no patients writh retention and none requiring reoperation, nor have we yet seen a recurrent ulcer. In terms of side effects these Indications patients are indistinguishable from those with In our early experience of proximal gastric straightforward proximal gastric vagotomy vagotomy many patients were excluded be- without drainage. cause of doubt about the adequacy of the outlet. Since 1972, when we first used duodeno- Discussion plasty, we have employed this manoeuvre in The importance of an intact pylorus in pre25 cases, over io% of all our proximal venting excessively rapid gastric emptying and gastric vagotomies. Two of the patients had in preventing duodenogastric reflux is now gross visible peristalsis of long standing and widely accepted. The clinical results of proxothers had severe fibrous stenosis. In some imal gastric vagotomy without drainage are cases the narrowing was due to active ulcerbetter than those of other forms of vagotomy ation, but this did not present any particular with drainage2, so it is worth while applying difficulty. Two of our patients had stenosis of this operation to paticnts with duodenal narthe second part of the duodenum. rowing. Digital dilatation involves an opening
14('
Terence Kennedy
in the stomach and a high risk of rupture of References the duodenum4. When there is a true fibrous i Amdrup, E, Jeinsen, H E, Johniston, D, Walker, B E, and Goligher, J C (I974) Annals of Surstricture forcible dilatation must surely be gery, i8o, 279. associated with some risk of restenosis if one G W, MacRac, K D, anid can extrapolate from the results of dilatation 2 Kennedy, T, Johnston, A Spencer, E F British Medical Joztrnal, (I975) of urethral strictures. 2, 30I. With duodenoplasty the muscular funcD (1973) in Vagoomy on T'rial ed. tion of the antrum and pylorus is preserved, 3 Johnston, Cox, A G and Alexander-Williams, J London, but we do not know the effect on duodenal Heinemann. motility, nor do we know whether the duo- 4 Johnston, D, Lyndon, P J, Smith, R B, and denal braking mechanism is in any way disHumphrey, C S (1973) British Journal of Surgery,
turbed. The early clinical results suggest that there are no important adverse effects.
6o, 790. 5 Kirk, R M (I970) Proceedings of Royal Society of Medicine, 63, 46.
ASPECTS OF TREATMENT*
Duodenoplasty with proximal gastric vagotomy Terence Kennedy MS FRCS Consultant Surgeon and Lecturer in Gastroenterological Surgery, Royal Victoria Hospital and Queen's University, Belfast
Summary To permit proximal gastric vagotomy without drainage in patients with gross duodenal narrowing a simple longitudinal incision, sutured transversely, has been found to be simple and safe. Early follow-up results have been satisfactory. Introduction Much evidence has accumulated of the superiority of proximal gastric vagotomy (highly selective vagotomy) without drainage in the routine treatment of chronic duodenal ulcer",2. Unfortunately this technique has not been generally applicable where there is mechanical obstruction to gastric emptying pyloric stenosis. Johnston' first excluded these cases but later described digital dilatation, though this led to perforation of the duodenal wall in 4 of I 5 dilatations'4. It is well known that 'pyloric' stenosis is, in fact, usually a duodenal stenosis and we have found that the point of narrowing is uisually I .5 cm or more beyond the pyloric ring. Where there is pseudodiverticular formation the narrowing occuirs beyond the pouches. It occurred to uis that in this group of cases a Heineke-Mickulicz 'pyloroplasty' could be performed more distally, leaving the important pyloric ring intact, thus permitting proximal gastric vagotomy without drainage.
through the pylorus may give better evidence. When there is an inadequate lumen a duodenoplasty is required. To facilitate access the second part of the duodenum is first mobilized by Kocher's manoeuvre A longitudinal incision is then made across the stricture and extended for 1-2 cm on either side, but it must not cross the pyloric ring (Fig. i), which is idcntified by the pyloric vein of Mayo and by palpation. In our experience the length of incision has varied between 2 and 6 cm. To avoid haemorrihage we normally make this incision with a cauitery knife, but diathermy can be used. It is generally easiest to open the duodenum distally, in-
Operative technique When the duodenum is exposed and the presence of ulceration or scarring is confirmed an estimate of the adequacy of the outlet must be made. Palpation between index finger and thumb or invagination5 will usually provide the answer, but occasionally the passage of FIG. I The incision is started distally and a large (3o F gauge) nasoga-stric tube down continued proximally through the stricture. *Fellows and Members interested in submitting papers for considerationi with a publication in this series should first wvrite to the Editor.
Xview to
Duodenoplasty with proximal gastric vagotomy
FIG. 2)
denal
After transverse suture achieved.
a
wide duo-
lumen is
a pair of forceps in a retrograde fashion, and ctut down on this instrument. The integrity of the pyloric muscle ring is confirmed and the index finger is gently passed back into the antrum to exclude any pyloric mucosal diaphragm or other narrowing. The incision is then closed transversely using two layers of chromic catgaut; one layer of sutures would probably be perfectlv satisfactory (Fig. 2). The operation is concluded by proximal gastric vagotomy, leaving intact the nerves of Latarjet to the distal 6 cm of antrum, measured from the pyloric ring.
sert
I145
When operation is performed for acute haemorrhage from a chronic duodenal ulcer it is virtually certain that the ulcer will be found on the posterior wall eroding the gastroduodenal artery. It is orthodox to expose the bleeding point through a long pyloroduodenotomy, under-run the vessel, and complete the operation as a truncal vagotomy and pyloroplasty. We have found it simple and satisfactory to limit the exporure to a duodenotomy, close it as a duodenoplasty, and finish the operation as a proximal gastric vagotomy without drainage. Twice when attempting duodenoplasty we found it necessary to transgress the pyloric ring to obtain an adequate lumen. In each case this transgression was limited to 0.5 cm in the hope that at least a part of the control mechanism would be preserved. When this is done it seems advisable to do a proximal gastric vagotomy. Occasional patients with jejunal ulcer following gastrojejunostomy without vagotomy are still seen. In 5 of these patients we have closed the gastrojejunostomy and performed a proximal gastric vagotomy; 3 of these had gross narrowing of the duodenum with longhealed ulceration, which was easily dealt with by duodenoplasty.
Results There have been no deaths or major complications. With a maximum follow-up of 212 years no claims can yet be made for the longterm results. In the early follow-up we have had no patients writh retention and none requiring reoperation, nor have we yet seen a recurrent ulcer. In terms of side effects these Indications patients are indistinguishable from those with In our early experience of proximal gastric straightforward proximal gastric vagotomy vagotomy many patients were excluded be- without drainage. cause of doubt about the adequacy of the outlet. Since 1972, when we first used duodeno- Discussion plasty, we have employed this manoeuvre in The importance of an intact pylorus in pre25 cases, over io% of all our proximal venting excessively rapid gastric emptying and gastric vagotomies. Two of the patients had in preventing duodenogastric reflux is now gross visible peristalsis of long standing and widely accepted. The clinical results of proxothers had severe fibrous stenosis. In some imal gastric vagotomy without drainage are cases the narrowing was due to active ulcerbetter than those of other forms of vagotomy ation, but this did not present any particular with drainage2, so it is worth while applying difficulty. Two of our patients had stenosis of this operation to paticnts with duodenal narthe second part of the duodenum. rowing. Digital dilatation involves an opening
14('
Terence Kennedy
in the stomach and a high risk of rupture of References the duodenum4. When there is a true fibrous i Amdrup, E, Jeinsen, H E, Johniston, D, Walker, B E, and Goligher, J C (I974) Annals of Surstricture forcible dilatation must surely be gery, i8o, 279. associated with some risk of restenosis if one G W, MacRac, K D, anid can extrapolate from the results of dilatation 2 Kennedy, T, Johnston, A Spencer, E F British Medical Joztrnal, (I975) of urethral strictures. 2, 30I. With duodenoplasty the muscular funcD (1973) in Vagoomy on T'rial ed. tion of the antrum and pylorus is preserved, 3 Johnston, Cox, A G and Alexander-Williams, J London, but we do not know the effect on duodenal Heinemann. motility, nor do we know whether the duo- 4 Johnston, D, Lyndon, P J, Smith, R B, and denal braking mechanism is in any way disHumphrey, C S (1973) British Journal of Surgery,
turbed. The early clinical results suggest that there are no important adverse effects.
6o, 790. 5 Kirk, R M (I970) Proceedings of Royal Society of Medicine, 63, 46.
