World J. Surg. 1, 19-27, 1977
9 19 7 by the Soci6t6 [nternationale de Chirurgic
Parietal Cell (Highly Selective or Proximal Gastric) Vagotomy for Peptic Ulcer Disease ERIK AMDRUP, M.D., I:~I.D., DANIEL ANDERSEN, a n d HANS-ERIC JENSEN, M.D., PH.D.
M.D., PH.D.,
Department of Surgery, University of A arhus, A arhus, Denmark and Department of Surgery, Kommunehospitalet, Copenhagen, Denmark Parietal cell vagotomy has been in clinical use for 7 years in elective treatment of nonobstructive duodenal ulcer, and for even a shorter period for complicated cases and for gastric ulcer. The evolution of the surgical technique has not yet come to an end and the ability to perform the procedure is still improving. It can therefore be questioned, if this operation is yet ripe for a realistic clinical trial, and the great variation in recurrence rate reported in pilot series as well as in prospective randomized clinical trials points to the possibility that we will have to wait several years before the anticipated mean recurrence rate is known. At present it can be stated that even if gastric emptying is not quite undisturbed, the addition of a drainage procedure in nonobstructive cases is unnecessary. The same may be true in some patients with pyloric obstruction. Furthermore, the mortality rate is very low and the incidence of moderate-to-severe dumping and diarrhea is virtually nil.
Surgery for duodenal ulcer is based on the observation that healing often follows reduction in gastric acid secretion. The fasting and stimulated secretion from the parietal cells can be decreased by reducing their sensitivity to gastrin by a vagotomy, and a further reduction follows removal of the antrum. Which type of vagotomy should be preferred and whether or not an antrectomy should be added are still open questions. Three types of vagotomy are in clinical use (Fig. 1): truncal vagotomy (TV), selective gastric vagotomy (SGV), and parietal cell vagotomy (PCV). They all aim at complete denervation of the parietal cells. When SGV is used for this objective, . an unintended vagotomy of the antrum is performed, and TV includes cutting of the extragastric vagus fibers. Both procedures disturb gastric motility and delay gastric Reprint requests to." Erik Amdrup, M.D., Ph.D., Surgical Gastroenterological Dept. L., Kommunehospitalet, University of Aarhus, Aarhus, Denmark
emptying to the extent that a supplementary drainage operation is necessary [1, 2]. Increasing knowledge of the results after vagotomy and drainage has led to the disappointing conclusion that, even if mortality is less than after partial gastrectomy, ulcer recurrence rate is higher and the incidence of sequelae is the same [3, 4]. This pointed to the drainage procedure as the main cause of postoperative, meal-related complaints. The desire to avoid disturbing the normal pyloric function inspired the introduction of PCV [5-7]. The surgical technique has previously been described in detail [8-10]. The aim of the operation is to vagotomize only that part of the stomach containing the parietal ceils and to leave intact the vagal innervation of the antrum. The purpose of this surgical effort is to reduce acid secretion sufficiently for the duodenal ulcer to heal without changing gastric emptying rate. A new operation passes through three stages: animal experimental investigations, clinical pilot studies, and, at last, controlled prospective randomized comparison to the best operations previously used. During the clinical phase, experimental clinical studies further clarify the physiologic consequences of the operation. Animal
Experimental
Studies
Introductory animal experimental studies should ensure that the new operation is technically feasible and that the principal aims of the procedure are achieved. The preliminary studies showed that a vagotomy limited to the parietal cell mass could be performed, that postoperative insulin-stimulated acid secretion was scanty, and that gastric emptying rate was approximately unchanged, but also that 24-hr Heidenhain pouch (HP) secretion was increased after the operation [11]. Further experimental studies con-
World J. Surg, Vol. 1, No. 1, January 1977
20
TV
SGV
PCV
Fig. 1. The vagal nerves to the acid-producing part of the stomach come from above and to the right. The dissection at the cardia required for a complete denervation of this area is essentially the same whether a truncal (TV), selective gastric (SGV), or parietal cell vagotomy (PCV) is performed. PCV includes the further possibility of leaving innervated parietal cells at the antrum/corpus border.
firmed that PCV considerably reduces insulin- and histamine-stimulated acid secretion [12]. The rise in 24-hr HP acid secretion has been confirmed. However, this parameter reflects a combination of secretion during both fasting and feeding, The main increase in HP output after PCV occurs, in fact, during feeding while the fasting pouch secretion is minimal [13]. This is in agreement with studies on variations in serum gastrin concentration that showed an insignificant rise during fasting but a highly significant rise after food intake [14]. Motility and emptying studies have shown that liquids with or without nutritional components leave the stomach a little faster after PCV, whereas solids empty a little slower [15]. Gastric emptying rate depends on the degree of antral denervation, With increasing antral denervation gastric motility and emptying is increasingly disturbed and HP secretign as well as food-induced elevation in serum gastrin concentration is prolonged [16], The rise in serum gastrin concentration and the subsequent increase in Heidenhain pouch secretion following PCV (and other types of vagotomy) are thought to be caused by the decrease in vagally induced gastric acid secretion, and are at present recognized as unavoidable sequels to the denervation of the parietal cells.
Clinical Experimental Studies During the clinical trial surgeons and physiologists are motivated to perform clinical experimental studies, often to test the validity of observations in the animal laboratories. An uncontrolled comparison 2 to 3 months after surgery showed the same reduction in pentagastrin- and insulin-stimulated gastric acid secretion after SGV and PCV [17]. However, during the
first year after PCV a significant increase in basal and pentagastrin- and insulin-stimulated acid secretion was observed [18-20], A further small but significant rise in maximal acid secretion occurred in the following 4 years, while basal output remained stable [20]. Similar observations [21, 22] confirm that the reduction in spontaneous and stimulated acid secretion following PCV gradually decreases. The cause and the clinical importance are as yet unknown. However, the phenomenon is unwanted and the observation of a specially high increase in patients with recurrent ulcer or dyspepsia [23] urges surgeons to make every effort to perform any vagotomy as completely as possible. Refinements of intraoperative tests for completeness of vagotomy, therefore, are highly important [24]. Acid secretion studies in our controlled comparison [25] showed that PCV with and without a drainage procedure reduced pentagastrin-stimulated output less than SGV (Table 1), but the difference was not significant. The reduction was of the same percentage in patients with preoperative high and preoperative low acid secretion. During the first year after surgery the rise in pentagastrin peak acid output was small and insignificant in patients treated with SGV, although it was significant (p < 0.001) after PCV (Fig. 2). Clinical experimental studies have confirmed the rise in fasting and especially in food-stimulated serum gastrin concentrations following PCV [26; 27]. The importance for gastrin release of the vagal innervation to the antrum has been investigated by giving insulin to duodenal ulcer patients before and after this operation [28, 29]. Serum gastrin concentration rose during insulin hypoglycemia, most after the parietal cell Table i. Pentagastrin-stimulated gastric acid secretion before and 1 year after SGV and PCV (mean • PAO
PAO at 1 Year Before Operation
At
1 Year
as % of PAO Before Operation
SGV + D n = 107
34.8•
15.8ti.2
45.7
PCV • D n o 93
38.6,1.6
20.3•
51.5 o.l>p>0.05 t. test
In the Aarhus county vagotomy trial [25] comparison of intraoperative peak acid output (PAO) (6 gg Peptavlon| body weight intramuscularly) to postoperative values (10 #g Peptavlon| showed reduction after PCV with and without drainage (• to be insignificantly less than that after SGV + D.
E. Amdrup et al.: Parietal Cell Vagotomy
21
PAO
contrast, even the addition of a drainage procedure to SGV could not prevent a significant delay in gastric emptying [32].
mmoi/h
40
38.6_+1.6T~ 34.8_+1 . 2 ~ \
~
30
-- PCV_+Dn :93
~ T ~ . 9 _+1.2
20
' / ] - 1 4 5
Clinical Pilot Series
TSE
~___---3"
-_+t.1
203_+12
2.15.8 _+1.2
I0. - -
Bef'ore operation
SGV + D
n : 107
J_
SE
3 Months
12 Months after operation
after operation
Fig. 2. During the first postoperative year an insignificant increase in pentagastrin-stimulated peak acid output (PAO) occurred after selectivegastric vagotomy with drainage (SGV + D). The rise after parietal cell vagotomy with and without drainage (PCV + D) was significant (p < 0.001). From the Aarhus county vagotomy trial [25]. mass had been denervated. When insulin was given in combination with food intake, an initial inhibition of the food-induced increase in serum gastrin was observed after PCV with a drainage procedure and also after SGV [30]. This suggests that the inhibitory effect was not transmitted through the antral vagus. A late stimulation of the food-induced gastrin rise occurred after both PCV and SGV, but to a significant degree only after PCV, The vagal nerves to the antrum play a role in gastrin release, but the clinical importance in connection with PCV is still difficult to interpret. Gastric emptying is not completely unchanged after PCV. The denervation of the upper part of the stomach causes impairment of adaptive relaxation, resulting in a higher degree of antral distention after meals [31]. This may explain the occurrence of an initial gastric incontinence for liquids following PCV as well as after SGV. The complete emptying for fluids is approximately unchanged after PCV but is faster after SGV [2]. For a solid meal, only a slight delay in gastric emptying has been observed after PCV. In
Since PCV was adopted surprisingly quickly, clinical experience from a number of pilot series already exists. The obvious advantage of not opening the gastrointestinal tract has resulted in a low mortality rate, 0.3% in a worldwide survey of 5539 elective operations [33]. The only serious abdominal complication, lesser curve necrosis, was reported to occur in 10 patients in this study. Five of these patients died. This phenomenon seems specific for PCV and should be seriously suspected when postoperative abdominal complications occur, especially since these are quite infrequent. The initial question concerning the necessity of adding a drainage procedure to PCV has been solved by the results of the pilot series. Clinical s y m p t o m s of gastric stasis are infrequent, and less than 1% of the patients need a secondary drainage operation [22, 33]. Furthermore, when dumping and diarrhea occur, the intensity is mild [21, 23, 34-37], and the incidence compares to that reported in unoperated individuals [38]. The reported ulcer recurrence rates vary greatly (Table 2), and no valid conclusion is possible from our present knowledge. Firstly, observation time is still generally too short. Furthermore, the authors reporting their series are all highly experienced gastric surgeons who can be expected to obtain especially good results. On the other hand, included in the reported series are the first patients operated on, and, even for the expert surgeon, some training in any operative procedure is necessary for optimal results. It must be added that the evolution of a new surgical technique is a dynamic p r o c e s s - - i m p r o v e m e n t s are constantly being added. Thus, our own mobilization of the esophagus has been extended during the years from 2 up to 6 cm, and our dissection behind and to the left of this organ has been increasingly extensive, resulting in the finding of nerves that we certainly left intact some years ago. Furthermore, during the oper-
Table 2. Parietal cell vagotomy pilot series Author G. Grassi et al. [34] S. Hedenstedt [35] I. Liav~g,M. Roland [21] J. Holst-Christensenet al. [23] T. Kennedy et al. [36] J. Miguel [37]
No. of patients
Obs. period (years)
787 465 265 160 112 80
1-6 0.5-7 3-6 1-4 Mean 2.2 3-5
Recurrence 8 (1.1%) 5 (1%) 16 (6%) 14 (9%) 7 (6%) 6%
Dumping (slight)
Diarrhea (slight)
0.4% 10 (2%) 4 (2%)
0 0 5 Not severe
8 (7%) 5%
3(2%) 10%
The large series of Grassi et al. and Hedenstedt include some patients with a drainage procedure added to PCV. The patient material of Holst-Christensen et al. is an uncontrolled continuation of the randomized study of Kronborg and Madsen [40].
22
World J. Surg. Voi. 1, No. 1, January 1977
ation we n o w elevate the upper part o f the patient's trunk to let the organs sink caudally and thus gain better access to the cardia. However, at present nob o d y can state realistically the importance o f these efforts. In this connection it can be mentioned that the exact estimation o f the physiologic borderline between a n t r u m and corpus with a p H tube, as we advocated previously [9], is unnecessary. It m a y even lead those less experienced in this procedure to perf o r m an incomplete denervation. In general, the use o f a n a t o m i c l a n d m a r k s is safer [8, 10]. The C o p e n h a g e n pilot series [22] includes 126 patients operated on for d u o d e n a l ulcer in the period 1969-1972. N o patients died. One had a secondary drainage operation for pyloric stenosis caused by scarring during the healing. Because o f previous experiences after TV without a drainage procedure [l], our first years with PCV were characterized by considerable fear o f an a c c u m u l a t i o n o f secondary gastric ulcers. O n e of our early patients p r o b a b l y had an unnecessary a n t r e c t o m y for suspicion o f a gastric ulcer that was not found. U p to now the reports have not described such a disaster. In one series [21] 8 of 20 recurrent ulcers were gastric and 6 were prepyloric. However, in all other publications duodenal recurrence has been dominating. T w o o f o u r patients developed a gastric ulcer: one in connection with bronchial carcinoma and p r o b a b l y caused by gastric stasis because o f mediastinal metastasis invading the vagal nerves, and one during intensive salicylate intake. T h e latter ulcer healed when the medication was stopped. Fifty-nine patients from C o p e n h a g e n have been followed for m o r e than 5 years. At the 5th year follow-up, 2 had been treated for a duodenal recurrence by antrectomy, the total n u m b e r of recurrent ulcers being four (7%). At the 7th year, 2 further
patients had presented a duodenal recurrence, the rate rising to 10% in patients observed between 5 and 7 years. One had an emergency a n t r e c t o m y for massive bleeding. The other developed s y m p t o m s during a period of severe emotional disturbances and the ulcer healed with nonsurgical treatment. The Leeds pilot series was started at the same time as that in C o p e n h a g e n , and in 1975 it included a total of 250 patients [20]. N o recurrent ulcer developed. In a few patients (3 to 4%) recurrence was suspected but was excluded by radiologic examination and endoscopy. Two patients were reoperated on because of suspicion o f an ulcer that was not verified. These results are better than those obtained by us, perhaps because of a m o r e extensive denervation of the upper part of the antrum. This explanation is questioned, however, since reduction in acid secretion was surprisingly equal in the two centers [18, 19]. Randomized
Studies
In surgery it is necessary to p e r f o r m pilot studies before a controlled clinical trial is started. It is not fair to c o m p a r e a new procedure to one used for several years before at least some training in performing the new operation has been obtained. As mentioned above, efforts to improve a new surgical technique take place over several years. It can be seriously questioned whether it is still too early to c o n d u c t a trial o f PCV. However, a strong need has been felt and randomized studies have been started in several departments, including our own [25]. As in the pilot studies, the various controlled trials (Table 3) are in agreement concerning the lower incidence of d u m p i n g and diarrhea after PCV compared to v a g o t o m y and drainage. In the A a r h u s c o u n t y v a g o t o m y trial moderate d u m p i n g occurred in 5% o f patients after PCV, whereas 27% o f the
Table 3. Interim results of some randomized studies of PCV compared to other types of vagotomy combined with a drainage or antrectomy
Author C. Wastell et al. [39] O. Kronborg, P. Madsen [40] T. Kennedy et al. [36] P. Jordan [41] D. Andersen, H. Hoestrup, E. Amdrup [25]
Operation
No. of patients
PCV PCV + D PCV SGV + D PCV SGV + GJ PCV SGV + A PCV PCV + D SGV + D SGV + A
50 50 50 50 50 50 27 26 45 15 65 8
Obs. period (years) 2-5 2-5 1-4 1-4 Mean 2 Mean 2 1 1 2
Dumping (no.) Diarrhea Recurrence__ (no.) SlightModerate Severe Slight Moderate Severe 3 8 10 4 1 1 1 0 3 0 3 0
3 7 2 5 4 14 2 8 1 2 4 0
2 1 10 3 2 8 2 3 11 3
In Jordan's series only results of the 1-year follow-up are given.
2
3 3 3 10 2 5 0 2
1
0 4 2
Not severe
E. Amdrup et al.: Parietal Cell Vagotomy
patients treated with vagotomy and drainage or antrectomy had moderate or severe symptoms. (p < 0.005). Ulcer recurrence rate in the randomized studies shows the same variation as reported in the pilot series. None of the studies yet has a sufficiently long observation period. Surely more patients will report recurrent ulcer in each of the series. However, with an increasing number of patients treated and an increasing training of the surgeons, the differences in recurrence rate due to technical problems can be expected to decline, revealing the true recurrence rate based on the surgical physiology of the operation. PCV for Complications of Duodenal Ulcer
When the ulcer has led to pyloric obstruction, most surgeons prefer to add a drainage procedure, and it is then questionable if PCV offers any advantage compared to SGV, which is technically easier to perform. Trials to avoid the drainage procedure by digital dilatation of the pyloric stenosis through a gastrotomy and thus to make the use of PCV meaningful have shown favorable results [42, 43]. Another solution is a duodenoplasty, which does not destroy the pylorus [44]. Experience has also been reported showing that pyloric obstruction most often disappears when the duodenal ulcer heals after PCV [35]. PCV has also been used successfully as an emergency operation for massive bleeding in a few centers [35, 42] but the number of patients treated is still small. The bleeding ulcer is sutured through a duodenotomy that does not include the pylorus. The logical procedure of adding PCV to closure of a perforated duodenal ulcer has been more widely used [35, 37, 42]. The operation field is usually not soiled by gastric contents, and it is not more difficult to perform a PCV under these circumstances than in elective surgery. Experience from 22 patients treated in one of our departments showed no postoperative complications [45]. Two of the patients later developed a recurrent ulcer, but the average rate of recurrent ulcer symptoms after simple closure of the perforation is more than 50%. PCV for Gastric Ulcer
In accordance with most other surgeons, we use an antrectomy and preferably a gastroduodenal anastomosis for the treatment of gastric ulcer. Vagotomy is not the apparent choice for this type of ulcer, since the stimulated and especially the basal acid secretion are low, and gastric emptying is usually slow. Vagotomy delays gastric emptying [32], which should be a disadvantage. However, vagotomy is a less extensive operation and therefore is attractive in older
23
patients. One of the oldest studies [46] showed a very high ulcer recurrence rate after vagotomy and drainage for gastric ulcer. Randomized trials with a reasonable observation period still favor resection but have not reported significant differences in overall symptomatic results [47, 48]. In Sweden and England [35, 49] more than 100 patients have been treated for gastric ulcer with PCV, and so far none has develgped recurrence. A randomized trial with a 1- to 4-year observation period has up to now shown one recurrent ulcer in 35 patients treated with PCV and two recurrences in 35 patients treated with gastric resection [21]. Thus, reports concerning vagotomy including PCV for gastric ulcer are surprisingly promising. However, results of any treatment are even more difficult to assess for gastric than for duodenal ulcer. The spontaneous course of gastric ulcer disease is capricious. Furthermore, ulcer in the stomach can be provoked by salicylates and other drugs and heal when medication is stopped. Longer observation time and more controlled clinical trials are necessary. Comments
PCV has been met with great expectations and is already widely used. During 7 years a huge literature on this subject has accumulated, resulting in more knowledge than usual at this stage of the evolution of a new operation. It can be concluded that the mortality rate is quite low and that PCV in this respect can compete with the operations previously used. Stomach emptying is not completely unchanged after PCV. Liquids leave a little faster, especially initially, and solids a little slower. However, neither experimental studies nor clinical experience has given any evidence for the necessity of adding a drainage operation. PCV is not followed by gastric stasis more often than SGV with antrectomy. It is questionable if dumping and diarrhea occur with higher frequency in patients treated with PCV than in unoperated individuals. However, these sequelae can follow the operation in persons who never had them before. This may be caused by the slight alteration in gastric emptying for fluids. The accumulated clinical experience makes it possible to state that PCV involves only a minimal risk for severe dumping. If symptoms of this type arise, they can easily be treated by diet. Furthermore, alterations in bowel movements have been so slight and infrequent that the occurrence of severe diarrhea points to the possibility of accidental damage to extragastric vagal branches during the operation. For the above reasons PCV may be recommended for the routine elective treatment of nonobstructing duodenal ulcer with the reservation that the patient
24
a n d the surgeon m u s t a c c e p t t h a t the final cure in a certain, yet u n k n o w n , n u m b e r o f cases requires a s e c o n d a r y a n t r e c t o m y . This is also true for TV a n d for SGV, but the r e p o r t e d recurrence rate in pilot series as well as in r a n d o m i z e d trials at present is so v a r i a b l e t h a t it is i m p o s s i b l e to m a k e a realistic guess c o n c e r n i n g the a n t i c i p a t e d m e a n recurrence rate following PCV. This will be finalized only by future experiences. T h e present overall i m p r e s s i o n is t h a t PCV reduces acid secretion a little less and is foll o w e d by a little larger p o s t o p e r a t i v e rise in acid o u t p u t than o t h e r types o f v a g o t o m y . This m a y be due to technical p r o b l e m s , a n d these can be overcome. If PCV reduces acid secretion less a n d if it is followed by m o r e r e c u r r e n t ulcers t h a n S G V with a d r a i n a g e p r o c e d u r e , the possibility exists t h a t the inn e r v a t e d , u n d r a i n e d a n t r u m in s o m e p a t i e n t s c o n tains an u n k n o w n u l c e r - p r o v o k i n g factor, which at p r e s e n t we c a n n o t d e m o n s t r a t e p r e o p e r a t i v e l y . T h e a d d i t i o n o f P C V to the closure o f a p e r f o r a t e d d u o d e n a l ulcer seems n o t to increase the c o m p l i c a tion rate, and it is a logical choice in patients with a p r e v i o u s ulcer history who often need s u b s e q u e n t definitive surgery [45, 50]. Results o f PCV in o t h e r e m e r g e n c y situations a n d for gastric ulcer are p r o m ising b u t s h o u l d still be reserved for the centers which at p r e s e n t a r e e v a l u a t i n g these i n d i c a t i o n s .
R~sum~
La v a g u o t o m i e supra-sdlective des cellules paridtales est e m p l o y d e en clinique d e p u i s s e u l e m e n t sept ans d a n s le t r a i t e m e n t 61ectif des ulcdres d u o d d n a u x n o n - c o m p l i q u d s d ' o b s t r u c t i o n ; son e m p l o i dans le cas d'ulcdres d u o d d n a u x c o m p l i q u d s et d'ulcbres gastriques est encore plus rdcent. La t e c h n i q u e chirurgicale c o n t i n u e d ' d v o l u e r et de se perfectionner. O n p e u t doric se d e m a n d e r s'il est o p p o r t u n p o u r le m o m e n t de s o u m e t t r e cette o p d r a t i o n / t u n e 6tude clinique controlde; la g r a n d e variabilit6 r a p p o r t d e dans les taux de rdcidive lors des 6tudes pilotes aussi bien que des 6tudes p r o s p e c t i v e s laisse s u p p o s e r qu'il f a u d r a a t t e n d r e p l u s i e u r s anndes a v a n t q u e le vdrit a b l e t a u x m o y e n de r6cidive soit connu. P o u r le m o m e n t on peut dire q u e m~me si la v i d a n g e gastrique est ldg6rement affectde, l ' a d d i t i o n d ' u n e p r o cddure de d r a i n a g e n ' e s t p a s ndcessaire d a n s les cas non c o m p l i q u d s d ' o b s t r u c t i o n , I1 se p e u t marne que cette o b s e r v a t i o n s ' a p p l i q u e aussi "3+certains patients p o r t e u r s d ' o b s t r u c t i o n p y l o r i q u e . D e plus, le taux de m o r t a l i t 6 est bas, et l ' i n c i d e n c e de d i a r r h d e posto p d r a t o i r e et de s y n d r o m e de chasse g a s t r i q u e ( " d u m p i n g " ) m o d d r 6 o u sdvdre est p r a t i q u e m e n t nulle.
World J. Surg. Vol. 1, No. 1, January 1977 References
1. Dragstedt, L.R., Camp, E.H., Fritz, J.M.: Recurrence of gastric ulcer after complete vagotomy. Ann Surg. 130:843, 1949 2. Donovan, I.A., Clarke, R.I., Gunn, I.F., Alexander-Williams, J.: A comparison of gastric emptying at 3 and 12 months after proximal gastric and selective vagotomy without pyloroplasty. Br. J. Surg. 61:889, 1974 3. Amdrup, E.: Selective gastric vagotomy. Technique and early results of 178 consecutive operations. Proceedings of the XXIInd Congress of the Society for International Surgery, 1967, p. 474 4. Goligher, J.C., Pulvertaft, C.N., de Dombal, F.T,, Conyers, J.H., Duthie, H.L., Feather, D.B., Latchmore, A.J.C., Schoesmith, J.H,, Smiddy, F.G., Willson-Pepper, J.: Five-toeight-year results of Leeds/York controlled trial of elective surgery for duodenal ulcer. Br. Med. J. 2:781, 1968 5. Johnston, D., Wilkinson, A.R.: Selective vagotomy with innervated antrum without drainage for duodenal ulcer. Br. J. Surg. 56:626, 1969 6. Amdrup, E., Jensen, H.-E., Pedersen, G.: Vagotomi af parietalcellemassen. Proc. Dan. Surg. Soc.:131, 1969 7. Hedenstedt, S., Moberg, S.: Selective proximal vagotomy with and without pyloroplasty in treatment of duodenal ulcer. Advance Abstracts, 4th World Congress of Gastroenterology, Copenhagen, p. 432, 1970 8. Johnston, D., Wilkinson, A.R.: Highly selective vagotomy without a drainage procedure in the treatment of duodenal ulcer. Br. J, Surg. 57:289, 1970 9. Amdrup, E., Jensen, H.-E.: Selective vagotomy of the parietal cell mass preserving innervation of the undrained antrum. Gastroenterology 59:522, 1970 10. Goligher, J.C.: A technique for highly selective (parietal cell or proximal gastric) vagotomy for duodenal ulcer. Br. J. Surg. 61:337, 1974 11. Amdrup, B.M., Griffith, C.A.: Selective vagotomy of the parietal cell mass. I. With preservation of the innervated antrum and pylorus. Ann. Surg. 17(1:207, 1969 12. Hallenbeck, G.A., Gleysteen, J.: Proximal gastric vagotomy without "drainage." An experimental study. Ann. Surg. 179:608, 1974 13. Bond, J., Brandsborg, O., Brandsborg, M., Mikkelsen, K., Eriksen, P.O., Amdrup, E.: Parietal cell vagotomy in dogs. Influence on Heidenhain pouch acid secretion, serum gastrin concentration, gastric emptying and motility. Digestion 12:201, 1975 14. Brandsborg, O., Bond, J., Brandsborg, M., LCvgren, N.A., Amdrup, E.: Serum gastrin concentration before and after parietal cell vagotomy in man and dog. Acta Chit. Scand. 141:654, 1975 15. Wilbur, B.C., Kelly, K.A.: Effect of proximal gastric, complete gastric and truncaI vagotomy on canine gastric electric activity, motility and emptying. Ann. Surg. 178:295, 1973 16. Bond, J., Brandsborg, O., Brandsborg, M., Mil~kelsen, K., Eriksen, P.O., Amdrup, B.M.: Determination of the "borderline of stasis" in parietal cell vagotomy. Preliminary experimental studies. Bull. Soc. lnt, Chir. 5-6:405, 1974 17. Kragelund, g., Amdrup, E., Jensen, H.-E.: Pentapeptide and insulin stimulated gastric acid secretion in patients with duodenal ulcer before and after selective gastric vagotomy with antrum drainage. A comparison with results obtained from studies before and after parietal cell vagotomy with no drainage procedure. Ann. Surg. 176:649, 1972 18. Joht.ston, D., wilkinson, A.R., Humphrey, C.S., Smith, R.B., Goligher, J.C., Kragelund, E., Amdrup, E.: The effect of highly selective vagotomy on spontaneous and pentagastrin stimulated maximal acid output. Gastroenterology 64:1, 1973
E. Amdrup et al.: Parietal Cell Vagotomy
19. Johnston, D., Wilkinson, A.R., Humphrey, C.S., Smith, R.B., Gollgher, J.C., Kragelund, E., Amdrup, E.: The insulin test after highly selective (parietal cell) vagotomy. Gastroenterology 64:12,1973 20. Greenall, M.J., Lyndon, P.J., Goligher, J.C., Johnston, D.: Long-term effect of highly selective vagotomy on basal and maximal acid output in man. Gastroenterology 68:1421, 1975 21. Liav~g, I., Roland, M.: A six year material of proximal gastric vagotomy (PGV). I. Clinical results. II. Secretory studies. Abstracts of Papers, X Scandinavian Conference on Gastroenterology, Sept. 1975. Scand. J. Gastroenterol. ll:Suppl 38, 60, 1976 22. Jensen, H.-E., Amdrup, E.: Five to seven years after parietal cell vagotomy. Abstracts of papers, X Scandinavian Conference on Gastronterology, Sept. 1975. Scand. J. Gastroenterol. ll:Suppl 38, 62, 1976 23. Holst-Christensen, J., Hart Hansen, O., Pedersen, T., Kronborg, O.: Recurrent ulcer 1 to 4 years after proximal gastric vagotomy without drainage for duodenal and prepyloric ulcer. Abstracts of Papers, X Scandinavian Conference on Gastroenterology, Sept. i975. Stand. J. Gastroenterol. l l:Suppl 38, 63, 1976 24. Cumberland, H.V., Coupland, G.A.E.: Parietal cell vagotomy. Med. J. Aust. 2:39, 1975 25. Andersen, D., Hoestrup, H., Amdrup, E.: The Aarhus county vagotomy trial. Bull. Soc. Int. Chir. (in press) 26. Kronborg, O., Stadil, P., Rehfeld, J., Christiansen, P.M.: Relationship between serum gastrin concentrations and gastric acid secretion in duodenal ulcer patients before and after selective and highly selective vagotomy. Scand. J. Gastroenterol. 8:491, 1973 27. Jaffe, B.M., Clendinnen, B.C., Clarke, R.J., Alexander-Williams, J.: Effect of selective and proximal gastric vagotomy on serum gastrin. Gastroenterology 66:944, 1973 28. Hansky, I., Soveny, C., Korman, M.C.: Role of the vagus in insulin-mediated gastrin release. Gastroenterology 63:387, 1972 29. Stadil, F., Rehfeld, S.P.: Gastrin response to insulin after selective, highly selective and truncal vagotomy. Gastroenterology 66:7, 1974 30. Brandsborg, O., Brandsborg, M., Lc~vgren,N .A., Amdrup, E.: The effect of insulin on food stimulated secretion of gastrin after parietal cell vagotomy and selective gastric vagotomy. Scand. J. Gastroenterol. (in press) 31. Stadaas, J.O., Aune, S.: lntragastric pressure volume relationsh~p before and aftei" vagotomy. Acta Chir. Scand. 136:6i I, 1970 32. Brandsborg, O., Brandsborg, M., LC;vgren, N,A., Mikkelsen, K., Mciller, B., Rokkj~e~', M., Amdrup, E.: Influence of parietal cell vagotomy and selective gastric vagotomy on gastric emptying rate and serum gastrin concentration. Gastroenterology (in press) 33. Johnston, D.: Operative mortality and postoperative morbidity of highly selective vagotomy. Br. Med. J. 4:545, 1975
25
34. Grassi, G., Arecchia, C., Cantarelli, I., Grassi Jr., G.B.: Development and results of our studies of vagotomy: From selective total vagotomy to ultraselective vagotomy. Chit. Gastroenterol. 9~23, 1975 35. Hedenstedt, S.: Experiences of selective proximal vagotomy-SPV--400 cases of uncomplicated and complicated ulcers during 6 years. Chit. Gastroenterol. 9:205, 1975 36. Kennedy, T., Johnston, G.W., MacRae, K.D., Spencer, E.F.A.: Proximal gastric vagotomy: Interim results of a randomized controlled trial. Br. Med. J. 2:301, 1975 37. Miguel, J.: Vagotomia gastrica proximal sin drenaje en el tratamento de la ulcera duodenal. Rec. Esp. Enferm. Ap. Diges. 31:337, 1972 38. Nielsen, A.: Mhltidsbestemte gener hos normalpersoner. With an English summary: Postcibal symptoms in nonoperated individuals. Ugeskr. Laeger 135:2270, 1973 39. Wastell, C., Wilson, T., Pigott, H.: Proximal gastric vagotomy. Proc. R. Soc. Med. 67:1183, 1974 40. Kronborg, O., Madsen, P.: A controlled randomized trial of highly selective vagotomy versus selective vagotomy and pyloroplasty in the treatment of duodenal ulcer. Gut 16:268, 1975 41. Jordan, P.H.: A prospective study of parietal cell vagotomy and selective vagotomy--antrectomy for treatment of duodenal ulcer. Ann. Surg. 183:619, 1976 42. Johnston, D., Lyndon, P.J., Smith, R.B., Humphrey, C.S.: Highly selective vagotomy without a drainage procedure in the treatment of haemorrhage, perforation and pyloric stenosis due to peptic ulcer. Br. J. Surg. 60:790, 1973 43. McMahon, M.J., Greenall, M.J., Johnston, D., Goligher, J.C,: Highly selective vagotomy plus dilatation of the stenosis compared with truncal vagotomy and drainage in the treatment of pyloric stenosis secondary to duodenal ulceration. Gut (in
press ) 44. Kennedy, T.: Duodenoplasty and proximal gastric vagotomy for pyloric stenosis. Ann. R. Coll. Surg. Engl (in press). 45. Skovgaard, S., Hanberg Sr F., Bon6, J.: Differentiated surgical approach to perforated duodenal ulcer. Closure with and without parietal cell vagotomy. A preliminary report. Scand. J. Gastroenterol ll:Suppl 38, 71, I976 46. Zahn, R.L., Stemmer, E.A., Hom, L.W, Conolly, J.E.: Delayed recurrence of gastric ulcer following vagotomy and drainage procedure. Am. Surg. 34:757, 1968 47. Duthie, H.L., Kwang, N.K.: Vag0tomy or gastrectomy for gastric ulcer. Br. Med. J. 4:79, 1973 48. Madsen, P., Kronborg, O,, Hart Hansen, O., Pedersen, T.: Billroth I gastric resection versus truncal vagotomy and pyloroplasty in the treatment of gastric ulcer. Acta Chit. Scand. 142:151, 1976 49. Johnston, D., Humphrey, C.S., Smith, R.B., Wilkinsson, A.R.: Treatment of gastric ulcer by highly selective vagotomy without a drainage procedure. Br. J, Surg. 59:787, 1972 50. Skovgaard, S.: Late prognosis of,perforated duodenal ulcer treated by simple suture. Scand J. Gastroenterol ll:Suppl 38, 70, 1976
9 19 7 by the Soci6t6 [nternationale de Chirurgic
Parietal Cell (Highly Selective or Proximal Gastric) Vagotomy for Peptic Ulcer Disease ERIK AMDRUP, M.D., I:~I.D., DANIEL ANDERSEN, a n d HANS-ERIC JENSEN, M.D., PH.D.
M.D., PH.D.,
Department of Surgery, University of A arhus, A arhus, Denmark and Department of Surgery, Kommunehospitalet, Copenhagen, Denmark Parietal cell vagotomy has been in clinical use for 7 years in elective treatment of nonobstructive duodenal ulcer, and for even a shorter period for complicated cases and for gastric ulcer. The evolution of the surgical technique has not yet come to an end and the ability to perform the procedure is still improving. It can therefore be questioned, if this operation is yet ripe for a realistic clinical trial, and the great variation in recurrence rate reported in pilot series as well as in prospective randomized clinical trials points to the possibility that we will have to wait several years before the anticipated mean recurrence rate is known. At present it can be stated that even if gastric emptying is not quite undisturbed, the addition of a drainage procedure in nonobstructive cases is unnecessary. The same may be true in some patients with pyloric obstruction. Furthermore, the mortality rate is very low and the incidence of moderate-to-severe dumping and diarrhea is virtually nil.
Surgery for duodenal ulcer is based on the observation that healing often follows reduction in gastric acid secretion. The fasting and stimulated secretion from the parietal cells can be decreased by reducing their sensitivity to gastrin by a vagotomy, and a further reduction follows removal of the antrum. Which type of vagotomy should be preferred and whether or not an antrectomy should be added are still open questions. Three types of vagotomy are in clinical use (Fig. 1): truncal vagotomy (TV), selective gastric vagotomy (SGV), and parietal cell vagotomy (PCV). They all aim at complete denervation of the parietal cells. When SGV is used for this objective, . an unintended vagotomy of the antrum is performed, and TV includes cutting of the extragastric vagus fibers. Both procedures disturb gastric motility and delay gastric Reprint requests to." Erik Amdrup, M.D., Ph.D., Surgical Gastroenterological Dept. L., Kommunehospitalet, University of Aarhus, Aarhus, Denmark
emptying to the extent that a supplementary drainage operation is necessary [1, 2]. Increasing knowledge of the results after vagotomy and drainage has led to the disappointing conclusion that, even if mortality is less than after partial gastrectomy, ulcer recurrence rate is higher and the incidence of sequelae is the same [3, 4]. This pointed to the drainage procedure as the main cause of postoperative, meal-related complaints. The desire to avoid disturbing the normal pyloric function inspired the introduction of PCV [5-7]. The surgical technique has previously been described in detail [8-10]. The aim of the operation is to vagotomize only that part of the stomach containing the parietal ceils and to leave intact the vagal innervation of the antrum. The purpose of this surgical effort is to reduce acid secretion sufficiently for the duodenal ulcer to heal without changing gastric emptying rate. A new operation passes through three stages: animal experimental investigations, clinical pilot studies, and, at last, controlled prospective randomized comparison to the best operations previously used. During the clinical phase, experimental clinical studies further clarify the physiologic consequences of the operation. Animal
Experimental
Studies
Introductory animal experimental studies should ensure that the new operation is technically feasible and that the principal aims of the procedure are achieved. The preliminary studies showed that a vagotomy limited to the parietal cell mass could be performed, that postoperative insulin-stimulated acid secretion was scanty, and that gastric emptying rate was approximately unchanged, but also that 24-hr Heidenhain pouch (HP) secretion was increased after the operation [11]. Further experimental studies con-
World J. Surg, Vol. 1, No. 1, January 1977
20
TV
SGV
PCV
Fig. 1. The vagal nerves to the acid-producing part of the stomach come from above and to the right. The dissection at the cardia required for a complete denervation of this area is essentially the same whether a truncal (TV), selective gastric (SGV), or parietal cell vagotomy (PCV) is performed. PCV includes the further possibility of leaving innervated parietal cells at the antrum/corpus border.
firmed that PCV considerably reduces insulin- and histamine-stimulated acid secretion [12]. The rise in 24-hr HP acid secretion has been confirmed. However, this parameter reflects a combination of secretion during both fasting and feeding, The main increase in HP output after PCV occurs, in fact, during feeding while the fasting pouch secretion is minimal [13]. This is in agreement with studies on variations in serum gastrin concentration that showed an insignificant rise during fasting but a highly significant rise after food intake [14]. Motility and emptying studies have shown that liquids with or without nutritional components leave the stomach a little faster after PCV, whereas solids empty a little slower [15]. Gastric emptying rate depends on the degree of antral denervation, With increasing antral denervation gastric motility and emptying is increasingly disturbed and HP secretign as well as food-induced elevation in serum gastrin concentration is prolonged [16], The rise in serum gastrin concentration and the subsequent increase in Heidenhain pouch secretion following PCV (and other types of vagotomy) are thought to be caused by the decrease in vagally induced gastric acid secretion, and are at present recognized as unavoidable sequels to the denervation of the parietal cells.
Clinical Experimental Studies During the clinical trial surgeons and physiologists are motivated to perform clinical experimental studies, often to test the validity of observations in the animal laboratories. An uncontrolled comparison 2 to 3 months after surgery showed the same reduction in pentagastrin- and insulin-stimulated gastric acid secretion after SGV and PCV [17]. However, during the
first year after PCV a significant increase in basal and pentagastrin- and insulin-stimulated acid secretion was observed [18-20], A further small but significant rise in maximal acid secretion occurred in the following 4 years, while basal output remained stable [20]. Similar observations [21, 22] confirm that the reduction in spontaneous and stimulated acid secretion following PCV gradually decreases. The cause and the clinical importance are as yet unknown. However, the phenomenon is unwanted and the observation of a specially high increase in patients with recurrent ulcer or dyspepsia [23] urges surgeons to make every effort to perform any vagotomy as completely as possible. Refinements of intraoperative tests for completeness of vagotomy, therefore, are highly important [24]. Acid secretion studies in our controlled comparison [25] showed that PCV with and without a drainage procedure reduced pentagastrin-stimulated output less than SGV (Table 1), but the difference was not significant. The reduction was of the same percentage in patients with preoperative high and preoperative low acid secretion. During the first year after surgery the rise in pentagastrin peak acid output was small and insignificant in patients treated with SGV, although it was significant (p < 0.001) after PCV (Fig. 2). Clinical experimental studies have confirmed the rise in fasting and especially in food-stimulated serum gastrin concentrations following PCV [26; 27]. The importance for gastrin release of the vagal innervation to the antrum has been investigated by giving insulin to duodenal ulcer patients before and after this operation [28, 29]. Serum gastrin concentration rose during insulin hypoglycemia, most after the parietal cell Table i. Pentagastrin-stimulated gastric acid secretion before and 1 year after SGV and PCV (mean • PAO
PAO at 1 Year Before Operation
At
1 Year
as % of PAO Before Operation
SGV + D n = 107
34.8•
15.8ti.2
45.7
PCV • D n o 93
38.6,1.6
20.3•
51.5 o.l>p>0.05 t. test
In the Aarhus county vagotomy trial [25] comparison of intraoperative peak acid output (PAO) (6 gg Peptavlon| body weight intramuscularly) to postoperative values (10 #g Peptavlon| showed reduction after PCV with and without drainage (• to be insignificantly less than that after SGV + D.
E. Amdrup et al.: Parietal Cell Vagotomy
21
PAO
contrast, even the addition of a drainage procedure to SGV could not prevent a significant delay in gastric emptying [32].
mmoi/h
40
38.6_+1.6T~ 34.8_+1 . 2 ~ \
~
30
-- PCV_+Dn :93
~ T ~ . 9 _+1.2
20
' / ] - 1 4 5
Clinical Pilot Series
TSE
~___---3"
-_+t.1
203_+12
2.15.8 _+1.2
I0. - -
Bef'ore operation
SGV + D
n : 107
J_
SE
3 Months
12 Months after operation
after operation
Fig. 2. During the first postoperative year an insignificant increase in pentagastrin-stimulated peak acid output (PAO) occurred after selectivegastric vagotomy with drainage (SGV + D). The rise after parietal cell vagotomy with and without drainage (PCV + D) was significant (p < 0.001). From the Aarhus county vagotomy trial [25]. mass had been denervated. When insulin was given in combination with food intake, an initial inhibition of the food-induced increase in serum gastrin was observed after PCV with a drainage procedure and also after SGV [30]. This suggests that the inhibitory effect was not transmitted through the antral vagus. A late stimulation of the food-induced gastrin rise occurred after both PCV and SGV, but to a significant degree only after PCV, The vagal nerves to the antrum play a role in gastrin release, but the clinical importance in connection with PCV is still difficult to interpret. Gastric emptying is not completely unchanged after PCV. The denervation of the upper part of the stomach causes impairment of adaptive relaxation, resulting in a higher degree of antral distention after meals [31]. This may explain the occurrence of an initial gastric incontinence for liquids following PCV as well as after SGV. The complete emptying for fluids is approximately unchanged after PCV but is faster after SGV [2]. For a solid meal, only a slight delay in gastric emptying has been observed after PCV. In
Since PCV was adopted surprisingly quickly, clinical experience from a number of pilot series already exists. The obvious advantage of not opening the gastrointestinal tract has resulted in a low mortality rate, 0.3% in a worldwide survey of 5539 elective operations [33]. The only serious abdominal complication, lesser curve necrosis, was reported to occur in 10 patients in this study. Five of these patients died. This phenomenon seems specific for PCV and should be seriously suspected when postoperative abdominal complications occur, especially since these are quite infrequent. The initial question concerning the necessity of adding a drainage procedure to PCV has been solved by the results of the pilot series. Clinical s y m p t o m s of gastric stasis are infrequent, and less than 1% of the patients need a secondary drainage operation [22, 33]. Furthermore, when dumping and diarrhea occur, the intensity is mild [21, 23, 34-37], and the incidence compares to that reported in unoperated individuals [38]. The reported ulcer recurrence rates vary greatly (Table 2), and no valid conclusion is possible from our present knowledge. Firstly, observation time is still generally too short. Furthermore, the authors reporting their series are all highly experienced gastric surgeons who can be expected to obtain especially good results. On the other hand, included in the reported series are the first patients operated on, and, even for the expert surgeon, some training in any operative procedure is necessary for optimal results. It must be added that the evolution of a new surgical technique is a dynamic p r o c e s s - - i m p r o v e m e n t s are constantly being added. Thus, our own mobilization of the esophagus has been extended during the years from 2 up to 6 cm, and our dissection behind and to the left of this organ has been increasingly extensive, resulting in the finding of nerves that we certainly left intact some years ago. Furthermore, during the oper-
Table 2. Parietal cell vagotomy pilot series Author G. Grassi et al. [34] S. Hedenstedt [35] I. Liav~g,M. Roland [21] J. Holst-Christensenet al. [23] T. Kennedy et al. [36] J. Miguel [37]
No. of patients
Obs. period (years)
787 465 265 160 112 80
1-6 0.5-7 3-6 1-4 Mean 2.2 3-5
Recurrence 8 (1.1%) 5 (1%) 16 (6%) 14 (9%) 7 (6%) 6%
Dumping (slight)
Diarrhea (slight)
0.4% 10 (2%) 4 (2%)
0 0 5 Not severe
8 (7%) 5%
3(2%) 10%
The large series of Grassi et al. and Hedenstedt include some patients with a drainage procedure added to PCV. The patient material of Holst-Christensen et al. is an uncontrolled continuation of the randomized study of Kronborg and Madsen [40].
22
World J. Surg. Voi. 1, No. 1, January 1977
ation we n o w elevate the upper part o f the patient's trunk to let the organs sink caudally and thus gain better access to the cardia. However, at present nob o d y can state realistically the importance o f these efforts. In this connection it can be mentioned that the exact estimation o f the physiologic borderline between a n t r u m and corpus with a p H tube, as we advocated previously [9], is unnecessary. It m a y even lead those less experienced in this procedure to perf o r m an incomplete denervation. In general, the use o f a n a t o m i c l a n d m a r k s is safer [8, 10]. The C o p e n h a g e n pilot series [22] includes 126 patients operated on for d u o d e n a l ulcer in the period 1969-1972. N o patients died. One had a secondary drainage operation for pyloric stenosis caused by scarring during the healing. Because o f previous experiences after TV without a drainage procedure [l], our first years with PCV were characterized by considerable fear o f an a c c u m u l a t i o n o f secondary gastric ulcers. O n e of our early patients p r o b a b l y had an unnecessary a n t r e c t o m y for suspicion o f a gastric ulcer that was not found. U p to now the reports have not described such a disaster. In one series [21] 8 of 20 recurrent ulcers were gastric and 6 were prepyloric. However, in all other publications duodenal recurrence has been dominating. T w o o f o u r patients developed a gastric ulcer: one in connection with bronchial carcinoma and p r o b a b l y caused by gastric stasis because o f mediastinal metastasis invading the vagal nerves, and one during intensive salicylate intake. T h e latter ulcer healed when the medication was stopped. Fifty-nine patients from C o p e n h a g e n have been followed for m o r e than 5 years. At the 5th year follow-up, 2 had been treated for a duodenal recurrence by antrectomy, the total n u m b e r of recurrent ulcers being four (7%). At the 7th year, 2 further
patients had presented a duodenal recurrence, the rate rising to 10% in patients observed between 5 and 7 years. One had an emergency a n t r e c t o m y for massive bleeding. The other developed s y m p t o m s during a period of severe emotional disturbances and the ulcer healed with nonsurgical treatment. The Leeds pilot series was started at the same time as that in C o p e n h a g e n , and in 1975 it included a total of 250 patients [20]. N o recurrent ulcer developed. In a few patients (3 to 4%) recurrence was suspected but was excluded by radiologic examination and endoscopy. Two patients were reoperated on because of suspicion o f an ulcer that was not verified. These results are better than those obtained by us, perhaps because of a m o r e extensive denervation of the upper part of the antrum. This explanation is questioned, however, since reduction in acid secretion was surprisingly equal in the two centers [18, 19]. Randomized
Studies
In surgery it is necessary to p e r f o r m pilot studies before a controlled clinical trial is started. It is not fair to c o m p a r e a new procedure to one used for several years before at least some training in performing the new operation has been obtained. As mentioned above, efforts to improve a new surgical technique take place over several years. It can be seriously questioned whether it is still too early to c o n d u c t a trial o f PCV. However, a strong need has been felt and randomized studies have been started in several departments, including our own [25]. As in the pilot studies, the various controlled trials (Table 3) are in agreement concerning the lower incidence of d u m p i n g and diarrhea after PCV compared to v a g o t o m y and drainage. In the A a r h u s c o u n t y v a g o t o m y trial moderate d u m p i n g occurred in 5% o f patients after PCV, whereas 27% o f the
Table 3. Interim results of some randomized studies of PCV compared to other types of vagotomy combined with a drainage or antrectomy
Author C. Wastell et al. [39] O. Kronborg, P. Madsen [40] T. Kennedy et al. [36] P. Jordan [41] D. Andersen, H. Hoestrup, E. Amdrup [25]
Operation
No. of patients
PCV PCV + D PCV SGV + D PCV SGV + GJ PCV SGV + A PCV PCV + D SGV + D SGV + A
50 50 50 50 50 50 27 26 45 15 65 8
Obs. period (years) 2-5 2-5 1-4 1-4 Mean 2 Mean 2 1 1 2
Dumping (no.) Diarrhea Recurrence__ (no.) SlightModerate Severe Slight Moderate Severe 3 8 10 4 1 1 1 0 3 0 3 0
3 7 2 5 4 14 2 8 1 2 4 0
2 1 10 3 2 8 2 3 11 3
In Jordan's series only results of the 1-year follow-up are given.
2
3 3 3 10 2 5 0 2
1
0 4 2
Not severe
E. Amdrup et al.: Parietal Cell Vagotomy
patients treated with vagotomy and drainage or antrectomy had moderate or severe symptoms. (p < 0.005). Ulcer recurrence rate in the randomized studies shows the same variation as reported in the pilot series. None of the studies yet has a sufficiently long observation period. Surely more patients will report recurrent ulcer in each of the series. However, with an increasing number of patients treated and an increasing training of the surgeons, the differences in recurrence rate due to technical problems can be expected to decline, revealing the true recurrence rate based on the surgical physiology of the operation. PCV for Complications of Duodenal Ulcer
When the ulcer has led to pyloric obstruction, most surgeons prefer to add a drainage procedure, and it is then questionable if PCV offers any advantage compared to SGV, which is technically easier to perform. Trials to avoid the drainage procedure by digital dilatation of the pyloric stenosis through a gastrotomy and thus to make the use of PCV meaningful have shown favorable results [42, 43]. Another solution is a duodenoplasty, which does not destroy the pylorus [44]. Experience has also been reported showing that pyloric obstruction most often disappears when the duodenal ulcer heals after PCV [35]. PCV has also been used successfully as an emergency operation for massive bleeding in a few centers [35, 42] but the number of patients treated is still small. The bleeding ulcer is sutured through a duodenotomy that does not include the pylorus. The logical procedure of adding PCV to closure of a perforated duodenal ulcer has been more widely used [35, 37, 42]. The operation field is usually not soiled by gastric contents, and it is not more difficult to perform a PCV under these circumstances than in elective surgery. Experience from 22 patients treated in one of our departments showed no postoperative complications [45]. Two of the patients later developed a recurrent ulcer, but the average rate of recurrent ulcer symptoms after simple closure of the perforation is more than 50%. PCV for Gastric Ulcer
In accordance with most other surgeons, we use an antrectomy and preferably a gastroduodenal anastomosis for the treatment of gastric ulcer. Vagotomy is not the apparent choice for this type of ulcer, since the stimulated and especially the basal acid secretion are low, and gastric emptying is usually slow. Vagotomy delays gastric emptying [32], which should be a disadvantage. However, vagotomy is a less extensive operation and therefore is attractive in older
23
patients. One of the oldest studies [46] showed a very high ulcer recurrence rate after vagotomy and drainage for gastric ulcer. Randomized trials with a reasonable observation period still favor resection but have not reported significant differences in overall symptomatic results [47, 48]. In Sweden and England [35, 49] more than 100 patients have been treated for gastric ulcer with PCV, and so far none has develgped recurrence. A randomized trial with a 1- to 4-year observation period has up to now shown one recurrent ulcer in 35 patients treated with PCV and two recurrences in 35 patients treated with gastric resection [21]. Thus, reports concerning vagotomy including PCV for gastric ulcer are surprisingly promising. However, results of any treatment are even more difficult to assess for gastric than for duodenal ulcer. The spontaneous course of gastric ulcer disease is capricious. Furthermore, ulcer in the stomach can be provoked by salicylates and other drugs and heal when medication is stopped. Longer observation time and more controlled clinical trials are necessary. Comments
PCV has been met with great expectations and is already widely used. During 7 years a huge literature on this subject has accumulated, resulting in more knowledge than usual at this stage of the evolution of a new operation. It can be concluded that the mortality rate is quite low and that PCV in this respect can compete with the operations previously used. Stomach emptying is not completely unchanged after PCV. Liquids leave a little faster, especially initially, and solids a little slower. However, neither experimental studies nor clinical experience has given any evidence for the necessity of adding a drainage operation. PCV is not followed by gastric stasis more often than SGV with antrectomy. It is questionable if dumping and diarrhea occur with higher frequency in patients treated with PCV than in unoperated individuals. However, these sequelae can follow the operation in persons who never had them before. This may be caused by the slight alteration in gastric emptying for fluids. The accumulated clinical experience makes it possible to state that PCV involves only a minimal risk for severe dumping. If symptoms of this type arise, they can easily be treated by diet. Furthermore, alterations in bowel movements have been so slight and infrequent that the occurrence of severe diarrhea points to the possibility of accidental damage to extragastric vagal branches during the operation. For the above reasons PCV may be recommended for the routine elective treatment of nonobstructing duodenal ulcer with the reservation that the patient
24
a n d the surgeon m u s t a c c e p t t h a t the final cure in a certain, yet u n k n o w n , n u m b e r o f cases requires a s e c o n d a r y a n t r e c t o m y . This is also true for TV a n d for SGV, but the r e p o r t e d recurrence rate in pilot series as well as in r a n d o m i z e d trials at present is so v a r i a b l e t h a t it is i m p o s s i b l e to m a k e a realistic guess c o n c e r n i n g the a n t i c i p a t e d m e a n recurrence rate following PCV. This will be finalized only by future experiences. T h e present overall i m p r e s s i o n is t h a t PCV reduces acid secretion a little less and is foll o w e d by a little larger p o s t o p e r a t i v e rise in acid o u t p u t than o t h e r types o f v a g o t o m y . This m a y be due to technical p r o b l e m s , a n d these can be overcome. If PCV reduces acid secretion less a n d if it is followed by m o r e r e c u r r e n t ulcers t h a n S G V with a d r a i n a g e p r o c e d u r e , the possibility exists t h a t the inn e r v a t e d , u n d r a i n e d a n t r u m in s o m e p a t i e n t s c o n tains an u n k n o w n u l c e r - p r o v o k i n g factor, which at p r e s e n t we c a n n o t d e m o n s t r a t e p r e o p e r a t i v e l y . T h e a d d i t i o n o f P C V to the closure o f a p e r f o r a t e d d u o d e n a l ulcer seems n o t to increase the c o m p l i c a tion rate, and it is a logical choice in patients with a p r e v i o u s ulcer history who often need s u b s e q u e n t definitive surgery [45, 50]. Results o f PCV in o t h e r e m e r g e n c y situations a n d for gastric ulcer are p r o m ising b u t s h o u l d still be reserved for the centers which at p r e s e n t a r e e v a l u a t i n g these i n d i c a t i o n s .
R~sum~
La v a g u o t o m i e supra-sdlective des cellules paridtales est e m p l o y d e en clinique d e p u i s s e u l e m e n t sept ans d a n s le t r a i t e m e n t 61ectif des ulcdres d u o d d n a u x n o n - c o m p l i q u d s d ' o b s t r u c t i o n ; son e m p l o i dans le cas d'ulcdres d u o d d n a u x c o m p l i q u d s et d'ulcbres gastriques est encore plus rdcent. La t e c h n i q u e chirurgicale c o n t i n u e d ' d v o l u e r et de se perfectionner. O n p e u t doric se d e m a n d e r s'il est o p p o r t u n p o u r le m o m e n t de s o u m e t t r e cette o p d r a t i o n / t u n e 6tude clinique controlde; la g r a n d e variabilit6 r a p p o r t d e dans les taux de rdcidive lors des 6tudes pilotes aussi bien que des 6tudes p r o s p e c t i v e s laisse s u p p o s e r qu'il f a u d r a a t t e n d r e p l u s i e u r s anndes a v a n t q u e le vdrit a b l e t a u x m o y e n de r6cidive soit connu. P o u r le m o m e n t on peut dire q u e m~me si la v i d a n g e gastrique est ldg6rement affectde, l ' a d d i t i o n d ' u n e p r o cddure de d r a i n a g e n ' e s t p a s ndcessaire d a n s les cas non c o m p l i q u d s d ' o b s t r u c t i o n , I1 se p e u t marne que cette o b s e r v a t i o n s ' a p p l i q u e aussi "3+certains patients p o r t e u r s d ' o b s t r u c t i o n p y l o r i q u e . D e plus, le taux de m o r t a l i t 6 est bas, et l ' i n c i d e n c e de d i a r r h d e posto p d r a t o i r e et de s y n d r o m e de chasse g a s t r i q u e ( " d u m p i n g " ) m o d d r 6 o u sdvdre est p r a t i q u e m e n t nulle.
World J. Surg. Vol. 1, No. 1, January 1977 References
1. Dragstedt, L.R., Camp, E.H., Fritz, J.M.: Recurrence of gastric ulcer after complete vagotomy. Ann Surg. 130:843, 1949 2. Donovan, I.A., Clarke, R.I., Gunn, I.F., Alexander-Williams, J.: A comparison of gastric emptying at 3 and 12 months after proximal gastric and selective vagotomy without pyloroplasty. Br. J. Surg. 61:889, 1974 3. Amdrup, E.: Selective gastric vagotomy. Technique and early results of 178 consecutive operations. Proceedings of the XXIInd Congress of the Society for International Surgery, 1967, p. 474 4. Goligher, J.C., Pulvertaft, C.N., de Dombal, F.T,, Conyers, J.H., Duthie, H.L., Feather, D.B., Latchmore, A.J.C., Schoesmith, J.H,, Smiddy, F.G., Willson-Pepper, J.: Five-toeight-year results of Leeds/York controlled trial of elective surgery for duodenal ulcer. Br. Med. J. 2:781, 1968 5. Johnston, D., Wilkinson, A.R.: Selective vagotomy with innervated antrum without drainage for duodenal ulcer. Br. J. Surg. 56:626, 1969 6. Amdrup, E., Jensen, H.-E., Pedersen, G.: Vagotomi af parietalcellemassen. Proc. Dan. Surg. Soc.:131, 1969 7. Hedenstedt, S., Moberg, S.: Selective proximal vagotomy with and without pyloroplasty in treatment of duodenal ulcer. Advance Abstracts, 4th World Congress of Gastroenterology, Copenhagen, p. 432, 1970 8. Johnston, D., Wilkinson, A.R.: Highly selective vagotomy without a drainage procedure in the treatment of duodenal ulcer. Br. J, Surg. 57:289, 1970 9. Amdrup, E., Jensen, H.-E.: Selective vagotomy of the parietal cell mass preserving innervation of the undrained antrum. Gastroenterology 59:522, 1970 10. Goligher, J.C.: A technique for highly selective (parietal cell or proximal gastric) vagotomy for duodenal ulcer. Br. J. Surg. 61:337, 1974 11. Amdrup, B.M., Griffith, C.A.: Selective vagotomy of the parietal cell mass. I. With preservation of the innervated antrum and pylorus. Ann. Surg. 17(1:207, 1969 12. Hallenbeck, G.A., Gleysteen, J.: Proximal gastric vagotomy without "drainage." An experimental study. Ann. Surg. 179:608, 1974 13. Bond, J., Brandsborg, O., Brandsborg, M., Mikkelsen, K., Eriksen, P.O., Amdrup, E.: Parietal cell vagotomy in dogs. Influence on Heidenhain pouch acid secretion, serum gastrin concentration, gastric emptying and motility. Digestion 12:201, 1975 14. Brandsborg, O., Bond, J., Brandsborg, M., LCvgren, N.A., Amdrup, E.: Serum gastrin concentration before and after parietal cell vagotomy in man and dog. Acta Chit. Scand. 141:654, 1975 15. Wilbur, B.C., Kelly, K.A.: Effect of proximal gastric, complete gastric and truncaI vagotomy on canine gastric electric activity, motility and emptying. Ann. Surg. 178:295, 1973 16. Bond, J., Brandsborg, O., Brandsborg, M., Mil~kelsen, K., Eriksen, P.O., Amdrup, B.M.: Determination of the "borderline of stasis" in parietal cell vagotomy. Preliminary experimental studies. Bull. Soc. lnt, Chir. 5-6:405, 1974 17. Kragelund, g., Amdrup, E., Jensen, H.-E.: Pentapeptide and insulin stimulated gastric acid secretion in patients with duodenal ulcer before and after selective gastric vagotomy with antrum drainage. A comparison with results obtained from studies before and after parietal cell vagotomy with no drainage procedure. Ann. Surg. 176:649, 1972 18. Joht.ston, D., wilkinson, A.R., Humphrey, C.S., Smith, R.B., Goligher, J.C., Kragelund, E., Amdrup, E.: The effect of highly selective vagotomy on spontaneous and pentagastrin stimulated maximal acid output. Gastroenterology 64:1, 1973
E. Amdrup et al.: Parietal Cell Vagotomy
19. Johnston, D., Wilkinson, A.R., Humphrey, C.S., Smith, R.B., Gollgher, J.C., Kragelund, E., Amdrup, E.: The insulin test after highly selective (parietal cell) vagotomy. Gastroenterology 64:12,1973 20. Greenall, M.J., Lyndon, P.J., Goligher, J.C., Johnston, D.: Long-term effect of highly selective vagotomy on basal and maximal acid output in man. Gastroenterology 68:1421, 1975 21. Liav~g, I., Roland, M.: A six year material of proximal gastric vagotomy (PGV). I. Clinical results. II. Secretory studies. Abstracts of Papers, X Scandinavian Conference on Gastroenterology, Sept. 1975. Scand. J. Gastroenterol. ll:Suppl 38, 60, 1976 22. Jensen, H.-E., Amdrup, E.: Five to seven years after parietal cell vagotomy. Abstracts of papers, X Scandinavian Conference on Gastronterology, Sept. 1975. Scand. J. Gastroenterol. ll:Suppl 38, 62, 1976 23. Holst-Christensen, J., Hart Hansen, O., Pedersen, T., Kronborg, O.: Recurrent ulcer 1 to 4 years after proximal gastric vagotomy without drainage for duodenal and prepyloric ulcer. Abstracts of Papers, X Scandinavian Conference on Gastroenterology, Sept. i975. Stand. J. Gastroenterol. l l:Suppl 38, 63, 1976 24. Cumberland, H.V., Coupland, G.A.E.: Parietal cell vagotomy. Med. J. Aust. 2:39, 1975 25. Andersen, D., Hoestrup, H., Amdrup, E.: The Aarhus county vagotomy trial. Bull. Soc. Int. Chir. (in press) 26. Kronborg, O., Stadil, P., Rehfeld, J., Christiansen, P.M.: Relationship between serum gastrin concentrations and gastric acid secretion in duodenal ulcer patients before and after selective and highly selective vagotomy. Scand. J. Gastroenterol. 8:491, 1973 27. Jaffe, B.M., Clendinnen, B.C., Clarke, R.J., Alexander-Williams, J.: Effect of selective and proximal gastric vagotomy on serum gastrin. Gastroenterology 66:944, 1973 28. Hansky, I., Soveny, C., Korman, M.C.: Role of the vagus in insulin-mediated gastrin release. Gastroenterology 63:387, 1972 29. Stadil, F., Rehfeld, S.P.: Gastrin response to insulin after selective, highly selective and truncal vagotomy. Gastroenterology 66:7, 1974 30. Brandsborg, O., Brandsborg, M., Lc~vgren,N .A., Amdrup, E.: The effect of insulin on food stimulated secretion of gastrin after parietal cell vagotomy and selective gastric vagotomy. Scand. J. Gastroenterol. (in press) 31. Stadaas, J.O., Aune, S.: lntragastric pressure volume relationsh~p before and aftei" vagotomy. Acta Chir. Scand. 136:6i I, 1970 32. Brandsborg, O., Brandsborg, M., LC;vgren, N,A., Mikkelsen, K., Mciller, B., Rokkj~e~', M., Amdrup, E.: Influence of parietal cell vagotomy and selective gastric vagotomy on gastric emptying rate and serum gastrin concentration. Gastroenterology (in press) 33. Johnston, D.: Operative mortality and postoperative morbidity of highly selective vagotomy. Br. Med. J. 4:545, 1975
25
34. Grassi, G., Arecchia, C., Cantarelli, I., Grassi Jr., G.B.: Development and results of our studies of vagotomy: From selective total vagotomy to ultraselective vagotomy. Chit. Gastroenterol. 9~23, 1975 35. Hedenstedt, S.: Experiences of selective proximal vagotomy-SPV--400 cases of uncomplicated and complicated ulcers during 6 years. Chit. Gastroenterol. 9:205, 1975 36. Kennedy, T., Johnston, G.W., MacRae, K.D., Spencer, E.F.A.: Proximal gastric vagotomy: Interim results of a randomized controlled trial. Br. Med. J. 2:301, 1975 37. Miguel, J.: Vagotomia gastrica proximal sin drenaje en el tratamento de la ulcera duodenal. Rec. Esp. Enferm. Ap. Diges. 31:337, 1972 38. Nielsen, A.: Mhltidsbestemte gener hos normalpersoner. With an English summary: Postcibal symptoms in nonoperated individuals. Ugeskr. Laeger 135:2270, 1973 39. Wastell, C., Wilson, T., Pigott, H.: Proximal gastric vagotomy. Proc. R. Soc. Med. 67:1183, 1974 40. Kronborg, O., Madsen, P.: A controlled randomized trial of highly selective vagotomy versus selective vagotomy and pyloroplasty in the treatment of duodenal ulcer. Gut 16:268, 1975 41. Jordan, P.H.: A prospective study of parietal cell vagotomy and selective vagotomy--antrectomy for treatment of duodenal ulcer. Ann. Surg. 183:619, 1976 42. Johnston, D., Lyndon, P.J., Smith, R.B., Humphrey, C.S.: Highly selective vagotomy without a drainage procedure in the treatment of haemorrhage, perforation and pyloric stenosis due to peptic ulcer. Br. J. Surg. 60:790, 1973 43. McMahon, M.J., Greenall, M.J., Johnston, D., Goligher, J.C,: Highly selective vagotomy plus dilatation of the stenosis compared with truncal vagotomy and drainage in the treatment of pyloric stenosis secondary to duodenal ulceration. Gut (in
press ) 44. Kennedy, T.: Duodenoplasty and proximal gastric vagotomy for pyloric stenosis. Ann. R. Coll. Surg. Engl (in press). 45. Skovgaard, S., Hanberg Sr F., Bon6, J.: Differentiated surgical approach to perforated duodenal ulcer. Closure with and without parietal cell vagotomy. A preliminary report. Scand. J. Gastroenterol ll:Suppl 38, 71, I976 46. Zahn, R.L., Stemmer, E.A., Hom, L.W, Conolly, J.E.: Delayed recurrence of gastric ulcer following vagotomy and drainage procedure. Am. Surg. 34:757, 1968 47. Duthie, H.L., Kwang, N.K.: Vag0tomy or gastrectomy for gastric ulcer. Br. Med. J. 4:79, 1973 48. Madsen, P., Kronborg, O,, Hart Hansen, O., Pedersen, T.: Billroth I gastric resection versus truncal vagotomy and pyloroplasty in the treatment of gastric ulcer. Acta Chit. Scand. 142:151, 1976 49. Johnston, D., Humphrey, C.S., Smith, R.B., Wilkinsson, A.R.: Treatment of gastric ulcer by highly selective vagotomy without a drainage procedure. Br. J, Surg. 59:787, 1972 50. Skovgaard, S.: Late prognosis of,perforated duodenal ulcer treated by simple suture. Scand J. Gastroenterol ll:Suppl 38, 70, 1976
