Postgraduate Medicine
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Role of vagotomy in duodenal ulcer Philip E. Donahue, Alain J. Marrie, Randall J. Krystosek & Lloyd M. Nyhus To cite this article: Philip E. Donahue, Alain J. Marrie, Randall J. Krystosek & Lloyd M. Nyhus (1977) Role of vagotomy in duodenal ulcer, Postgraduate Medicine, 62:4, 156-167, DOI: 10.1080/00325481.1977.11714649 To link to this article: http://dx.doi.org/10.1080/00325481.1977.11714649
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role of vagotomy in duodenal ulcer Philip E. Donahue, Alain J. Marrie, Randall J. Krystosek, Lloyd M. Nyhus,
MD MD MD MD
University of Illinois at the Medical Center Chicago
Vagotomy is a dynamic, evolving therapeutic tool rather than the "simple" operation it is sometimes assumed to be. Postoperative ulcer recurrence remains a problem, and the development of a foolproof peroperative test for completeness of vagotomy will be welcome.
• The evolution of surgical vagotomy in the treatment of abdominal disease is of interest for ali practitioners of medicine. When first introduced, vagotomy (as total gastric vagotomy) was performed for widely disparate clinical syndromes ranging from tabetic crisis to gastric ulceration. 1 Early investigators suspected that section of the vagus nerves led to a decrease in gastric acid production (still the most desirable effect of vagotomy). The modern era was heralded by Dragstedt and Owens2 in 1943, wh en they reported the use of transthoracic truncal vagotomy for duodenal ulcer. The earl y success of this operation led to hopes that the definitive treatment of duodenal ulcer had been discovered, but subsequent difficulties with gastric stasis proved these hopes to be futile. Nonetheless, the place of vagotomy in the treatment of duodenal ulcer had been firmly established. (ln 1956, Dragstedt3 hypothesized that duodenal ulcer relates primarily to a derangement of neural control of gastric secretion, a view that continues to provide the best explanation for the pathophysiology of this type of ulcer.) Knowledge of the anatomy of the vagi facilitates an understanding of the different types of vagotomy now being do ne and the rationale for each. An anatomical description and sorne related surgical considerations are given on page 158.
Cllnlcal Applications
Truncal vagotomy-Following the realization that gastric stasis occurred after trun cal vagotomy in up to 50% of patients, pyloroplasty or gastrojejunostomy for stomach drainage was added to the procedure. 4 .s The combined procedure has been used to treat more duodenal ulcers than any other operation in history. Interestingly, both truncal vagotomy and gastroenterostomy, when first introduced, were thought to be superb treatments for duodenal ulcer. With long-term follow-up, however, it became clear that either procedure alone was inadequate. Long-term results of the combined procedure (though excellent for sorne groups) have likewise been somewhat disappointing, the ulcer recurrence rate being about 10% in most series and up to 25% in Presented in part by Dr Nyhus as the Aiton Ochsner Lecture.
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others. 6 The cause for the high rate of recurrence is most often incomplete vagotomy, for reasons related to the anatomie arrangement of the esophageal plexus and the main vagal trunks at the esophageal hiatus. The high incidence of recurrent ulcer is not the only disadvantage of truncal vagotomy. Others are the occurrence of postvagotomy diarrhea, possible dysfunction of the pancreas or gallbladder, and risks associated with surgieal drainage of the stomach. Factors that have made the vagotomy-drainage procedure so attractive to surgeons are the low surgical mortality and the relative ease and rapidity of performance. The combined procedure bas ''legitimized'' surgie al treatment of duodenal ulcer, since it avoids the many complications of subtotal gastrectomy (high mortality, poor nutrition, high incidence of severe dumping syndrome) and can be readily performed by ali general surgeons. Selective vagotomy-Selective gastric vagotomy was developed in an attempt to achieve complete gastric denervation without damaging vagal nerve fibers running to other abdominal organs. Though frrst investigated by Wertheimer and Latarjet in 1922, the technique was not revived until the late 1940s. At that time, it was thought that if the pyloric branches of the gastrohepatic vagi were spared, the stomach might empty normally7; wh en gas tric emptying remained unsatisfactory, selective vagotomy was temporarily abandoned. The concept of adding a gastric drainage procedure to a complete vagotomy bad not yet been formulated. In 1960, Burge8 and Griffith9 independently reported the technique of selective vagotomy wtth antrectomy (removal of 25% to 40% of the stomach, including the pylorus)
for duodenal ulcer. The immediate reason for initiating these more recent investigations was to defme a madel of gastric denervation that could avoid the sequelae of truncal vagotomy (mainly diarrhea). White in many instances postvagotomy '' diarrhea'' consists merely of a change in frequency or in consistency of the bowel movement and as such causes little discomfort, in 1% to 2% of patients it is almost incapacitating. 10·11 In these patients, the propensity for unexpected and urgent bowel motions (often so sudden that incontinence results) may be so unnerving that any social interaction is feared. Therefore, an operation that minimizes this unpleasant syndrome would be advantageous. Of importance is the question ofhow effectively the stomach is denervated by the selective technique. If, as was thought, the vagi comprise two trunks at the esophageal hiatus and if the two trunks con tain ali of the gas tric vagi, then section of the trunks necessarily is a complete gastrie vagotomy. The selective technique, when viewed in the light of this assumption, can at most accomplish what truncal nerve division theoretieally assures. Such reasoning, though fallacious, still bas appeal to many surgeons. The crux of the problem lies in the anatomie distribution of the vagi, the manner in whieh the esophageal vagal plexus is reconstituted above the esophageal hiatus, and the possible earl y branching of the main vagal trunks proximal to the usual point of nerve transection in truncal vagotomy. Since the vagal system bas no embryologie or anatomie relation with the diaphragm, the vagi at the esophageal hiatus may exist in the form of an esophageal plexus, trunks, or truncal diviston12·13; a vagotomy procedure that aims
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vagotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
anatomy of the vagi and related surgical considerations Anatomy•
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There are two main vagal trunks, the anterior (left) and the posterior (right). They derive from the plexus of nerves surrounding the esophagus in the thorax. Cross-sectional studies of the upper abdomen rarely show only two trunks; instead, two to seven nerves have been found. This is due to the existence of communicating branches between the trunks and of early gastric branches going directly to the stomach.
Anterior Trunk This trunk (figure 1) is single in only one third of cases; more often, it is plexiform. lt is usually situated on the anterior wall of the esophagus bene ath the peritoneum overlying the gastroesophageal junction. Sometimes (rarely) it is situated at the left margin of the esophagus. The anterior trunk gives rise to two kinds of branches: Gastrohepatic-The gastrohepatic branches (Burge gastrohepatic plexus) are usually multiple but may be single. Coming from the right margin of the anterior trunk, just above the cardia, these nerves cross from left to right across the most cephalad portion of the lesser omentum to join the transverse fissure of the liver. At that point, a nerve with a recurrent course from the hepatic pedicle to the superior margin of the duodenum is seen. lt is called the Latarjet-pyloroduodenal pedicle and is constant anatomically. Gas tric (two types)- The esophagofundic branches, four to five in number, course directly to the lower esophagus and fundus of the stomach. The second gastric branch (first described by Wertheimer) is the principal anterior nerve of the lesser curvature. This large nerve is the major continuation of the anterior vagal trunk below esophagogastric branches, and is known as the nerve of Latarjet. lt descends alongside the lesser curvature, 2 cm to the right of it. From its left margin arise four to five gastric branches which cross directly to the stomach. The nerve of Latarjet terminales on the superior margin of the antrum, about 5 to 7 cm from the pylorus. The two or three terminal ramifications (the crow's foot) innervate the anterior wall of the antrum but never join the pylorus; recurrent branches from the more proximal ramifications of the crow's foot may innervate the distal corpus. Posterior Trunk The posterior trunk (figure 2) is usually situated behind the right margin of the esophagus; it may be
•o,"cription ha":J largd) on 'tudic' made by Wcnhcimcr (a 'tude ni of L~tarJdJ 111 1Y22 'upplcmcntcJ by rcu:nt di"c•t·tion' c~rncd out h) one of u' IR .J. K.) in the an~lomy lahoratory.
158
located more posteriorly on the right crus of the diaphragm. This trunk also gives rise to two branches: Celiac-This branch arises from the right margin and goes to the ce liac plexus, innervating the en tire digestive tract. One branch may travel through the celiac plexus and then behind the first portion of the duodenum (along the right gastroepiploic artery) to supply the parasympathetic innervation of the gastric greater curvature. This is called the gastroepiploic pedicle and sometimes also the pedicle of the greater curvature. Gastric (two types)-Esophagogastric branches originale from the left margin below the main celiac branch and are four to five in number. The second branch, the principal posterior nerve of the lesser curvature, is symmetric with the principal anterior nerve. (See figure 1.) lt descends along the lesser curvature and ends on the superior margin of the antrum without joining the pylorus. From its left margin arise four to five branches which innervate the corpus of the stomach.
Direct Gastric Branches Branches of esophageal vagal origin, arising either from the plexus or early from one of the trunks, cross the diaphragm directly and then join the fundus of the stomach. Most commonly recognized are early branches of the anterior or posterior trun k. ln approximately 10% of specimens, such direct gastric branches arise from the anterior trunk; however, the posterior trunk routinely gives rise to one or several direct gastric branches which cross behind the esophagus to join the posterior fundus (figure 2). Such branches are called criminal because they are likely to be forgotten or missed during operative dissection.
Surglcal Considerations · 1. Section of the vagal trunks above the gastric branches accomplishes parasympathetic denervation of the stomach and of the entire digestive tract (truncal vagotomy) (figure 3). 2. Section of the vagal trunks immediately distal to the gastrohepatic branch of the anterior vagus and the celiac branch of the posterior vagus, with division of esophagogastric branches, direct gastric branches (anterior and posterior), and nerves of Latarjet, accomplishes selective denervation of the stomach (selective vagotomy) (figure 4). 3. Section of the esophagogastric branches, the direct gastric branches, and the anterior and posterior gastric branches of the principal nerves of the lesser curvature (sparing the n'3rves of Latarjet), effects selective denervation of the fundus but not of the antrum (proximal gastric vagotomy) (figure 5). 4. lncomplete vagotomy may result if care is not taken to find ali branches to be sectioned in the chosen procedure.
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----li
Anterior vagus Posterior vagus -
Criminal nerve /
1
Posterior vagus "---.
i
!
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Ce liac branch
L____
--- _ _ _ _ _ _ _ _ j
Figure 1. Anterior (left) vagus nerva is depicted as being thick for ease of visualization; in reality it may be thin and difficult to recognize. If so, traction on the lasser curvature of the stomach tautens the nerve and aids in its identification. r------------------
Poste ri or vag us
--..:.--
....... __Gas~r~e~~lo~-pe-dic~~--__j \
Figure 2. Posterior (right) vagus nerve is usually much thicker than the anterior vagus. Note that first branches of the nerva could be missed if the left margin of the gastroesophageal junction were not carefully examined. Highest branch depicted is "criminal" nerve (direct gastric branch).
Figure 3. ln carrying out truncal vagotomy, a careful search for small direct branches must be made. They will be found in a high percentage of cases. Their division can best be insured by baring the esophagus of ali surrounding tissue at the point where the main vagal trunks are divided.
---~
-- Anterior vagus
/ Anterior vagus
t
Posterior vag us
Criminal nerve
i !
Ce liac
'
1
1
!
1
l__·- -
_j
Figure 4. Selective vagotomy spares vagal fibers of the hepatic and celiac plexuses. Preferred method of assuring division of ali vagal branches to the stomach is to clear lower 5 to 6 cm of the esophagus of ali surrounding tissues and to section main trunks distal to the hepatic and celiac branches.
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1
L_
Figure 5. Proximal gastric vagotomy attempts to denervate ali acid-secreting portions of the stomach, leaving the distal motor segment (antrum) innervated. Critical portions of dissection involve the gastroesophageal junction, which must be bared for 5 to 6 cm to assure division of ali criminal branches, and identification of distal extent of the acid-secreting tissues which should be denervated. ..,.
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vagotomy ............................................_
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Just as effective techniques for truncal and selective vagotomy had to be dlscovered and dlssemlnated, so also must techniques for proximal gastrlc vagotomy.
at mere identification and section oftwo vagal "nerves" risks incomplete section. 14 •15 Selective vagotomy accomplishes section of the vagal nerves at the point where their relation to the stomach is clear and their complete division can be more readily assured. However, care must be taken to find ali gastric branches, especialiy to the left margin of and behind the esophagus, to avoid incomplete section. In experimental and clinical models comparing truncal and selective vagotomy to determine which procedure results in greater reduction of acid secretion and ulcer recurrence, selective vagotomy bas often fared better. For this reason, it is the recommended procedure for elective vagotomy. Pyloroplasty or gastroenterostomy, however, must also be performed to aliow for gastric atony after division of motor nerves to the antrum. Proximal gas tric vagotomy-The next phase in the evolution of vagotomy for duodenal ulcer began in 1957, when proximal gastric vagotomy (also known as parietal celi vagotomy, selective proximal vagotomy, and highly selective vagotomy) was performed. 16 The desirable features of the operation ali relate to preservation of antral innervation. Since a stomach with antral innervation empties normally, no drainage procedure is required. Other beneficiai aspects are avoidance of contamination of the operative field by gastroduodenal contents, absence of adverse sequelae of vagotomy (diarrhea) and drainage procedures (dumping syndrome and reflux alkaline gastritis), and most important, almost zero chance of mortality. The frrst report of proximal gastric vagotomy carried out in a series of patients appeared in 1964_17 The procedure was combined with a "form and function" pyloroplasty, ie, pyloroplasty tailored to the presence or absence of scarring about the pylorus. In 1969, Amdrup and colleagues18 and Johnstan and Wilkinson19 began performing proximal gastric vagotomy without a drainage procedure, and since then the operation bas been done in over 5,000 patients. The procedure bas fulfilled ali expectations in terms of low mortality and absence of undesirable
sequelae--except for the recurrence of ulcer. How great is the risk of ulcer recurrence? The recurrence rate bas been reported to be 2% to 4% in the most favorable series and 20% to 28% in the least favorable. These are relatively short-term results, however. We remember with sorne trepidation that gastroenterostomy alone or truncal vagotomy with drainage for duodenal ulcer achieved excellent results initially, but long-term foliow-up showed a relatively high incidence of recurrence. It remains to be seen whether the his tory of proximal gastric vagotomy will follow the same course. If this procedure is successful in controliing duodenal ulcer, then perhaps the ideal operation will have been discovered. Ulcer recurrence is certainly a most serious complication, but the possibility must be considered in the context of an operation that bas al most no morbidity or mortality. Furthermore, if reoperation is necessary, surgery can be performed in an almost virgin abdomen. Future candidates for proximal gastric vagotomy will in ali probability have to decide what chance of recurrent ulcer they are willing to risk to a void the unpleasant side effects of the more conventional vagotomy procedures, particularly truncal vagotomy. The wide variance in ulcer recurrence rates after proximal gastric vagotomy in different series of patients appears to be due to differences in operative technique. Just as effective techniques for truncal and selective vagotomy bad to be discovered and disseminated, so also must techniques for this type of vagotomy. Recurrence after truncal vagotomy usually relates to vagal fibers left intact; the same may be true in proximal gastric vagotomy. The anatomie distribution of vagal fibers at the cardia of the stomach may explain this. 1t bad been thought that the vagal fibers to the stomach ali coalesced at the lesser curvature of the stomach, and that denervation of the acid-secreting cells could be accomplished by surgie al dissection of ali vagal fibers penetrating the stomach along the lesser curvature. This approach failed to adequately denervate the fundus of the stomach, because gastric
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vagotomy ..................................................... . Dr Donahue is assistant professer, department of surgery, University of Illinois Abraham Lincoln School of Medicine, Chicago. Dr Marrie collaborated with the other authors while on an extended visit to the University of Illinois. He is now assistant clinic chief, Center Hospital of the University of Strasbourg, Strasbourg, France. Dr Krystosek is a fellow in surgical anatomy, University of Illinois Hospital, Chicago. Dr Nyhus is Warren H. Cole Professer, and head, department of surgery, University of Illinois Abraham Lincoln School of Medicine.
Philip E. Donahue
branches may arise from the posterior vagus at a high leve! and enter the fundus of the stomach at the left side of the cardioesophageal junction (the "criminal" branches20 ). Lack of sufficient dissection appears to account for the initially high recurrence rates reported in sorne series. 21 It now appears that not only must the left side of the cardia be bared, but that the distal 5 to 7 cm of esophagus must be completely dissected from surrounding tissues to insure adequate denervation.22 This concept has received support by Hallenbeck and co-workers, 23 who modified their technique for proximal gastric vagotomy for duodenal ulcer when their recurrence rate for proved or suspected ulcer was alarmingly high (25% ). By incorporating meticulous and extensive periesophageal dissection, they had on! y one ulcer recurrence in 17 patients recent! y operated on. 23 A more radical approach to periesophageal dissection has been proposed by Herrington and Sawyers. 24 They advocate circumferential division of ali esophageal muscle layers Iying just above the gastroesophageal junetien, th us insuring division of ali of the "little nerve fibrils'' passing through the esophagus to the stomach. At the completion of this maneuver, the nasogastric tube in the esophagus can be seen through the denuded, transparent mucosa. This seems to us to be a possibly dangerous and probably unnecessary procedure. An additional consideration is the question of how far distally the nerves should be dissected. Two approaches are currently in use.
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In the anatomie approach, the major nerves of the lesser curvature (nerves of Latarjet) are spared, leaving 5 to 8 cm of the distal stomach innervated, while in the physiologie approach, a peroperative test of acid secretion is used to define the extent of the antrum (since the acid-secreting portions of the stomachthe fundus and the corpus-are the only portions intentionally denervated by proximal gastric vagotomy). While the anatomie and physiologie boundaries of acid-secreting mucosa and antral "pump" may coïncide, the matter is still unsettled, and further information will certainly be necessary before any precise approach is validated. We have used the transendoscopic Kusakari test25 •26 to define the distal extent of acid-secreting mucosa.
Tests for Completeness of Vagotomy No matter which type of vagotomy is performed, the question of completeness remains, since incomplete section accounts for the majority of ulcer recurrences. How is the completeness of vagotomy determined? A foolproof peroperative test would resolve this vexing problem and minimize the risk of performing an incomplete vagotomy at the first operation. Techniques currently used include the electrical stimulation test devised by Burge and Vane, 27 gastrotomy and pH probe measurements, and transendoscopic tests. 25 .2 6 Varying results from these have been reported, and an efficient, noncumbersome, peroperative test of vagal integrity remains to be developed. Theoretlcal Aspects of Vagotomy In the past, the beneficiai effects of vagotomy were thought to result from acetylcholine deficiency in cells previously innervated by the vagus nerves. Supporting this concept are the facts that vagotomy decreases basal and stimulated secretion of acid and th at it abolishes secretion of acid in response to cephalic vagal stimulation, such as occurs with 2-deoxy-o-glucose and from insulin hypoglycemia. However, the precise outcome of va-
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............................................... vagotomy gotomy may represent more than loss of parasympathetic stimulation. Ultrastructural studies of gastric mucosal cells after vagotomy show changes in sympathetic as weil as in parasympathetic nerve terminais, leading to speculation about the role (if any) of such nerve fibers in normal gastric function. Results of other investigations with antagonists of sympathetic nerve function support the thesis that the sympathetic system is intimately involved in normal gastric physiology.2s With increasing awareness of the complex dynamics of gastric secretion, other aspects of vagal function and structure are being considered in assessing the effects of vagal innervation. There are very few "ali or none" situations concerning gastric secretion-in most experimental models, the effects of hormones, neural influences, and endogenous mucosal secretion are combined. For example, the relation between an endocrine cell population in the gas tric mucosa and observed secretory effects is only beginning to be elucidated. Morphologie observation of autonomie nerve fibers within the vagal nerves may yield a final definition of the way in which the gastric mucosa synthesizes information and "decides" at a given time whether gastric secretion should be turned on or off. On the clinical side of the picture, the dramatic effects on inhibition of acid secretion of the histamine H2-receptor antagonists and prostaglandins may be the beginning of the end of "chronicity" of acute duodenal ulcer. Of course, ali conclusions reached in this regard
are at best preliminary and require meticulous long-term study.
Conclusion lt is clear that vagotomy is a dynamic, evolving therapeutic tool and not the unchanging •·simple'' operation it is sometimes assumed to be. Many questions about the procedure, its effects, and the best ways to use it to achieve maximum patient benefit remain to be answered. For the present, a patient who requires surgery for ulcer should receive the operation which is best suited for the disease process and most familiar to the surgeon. There should be no misunderstanding about the fact that truncal vagotomy is an extremely useful operative procedure for duodenal ulcer and that most patients who undergo this procedure are quite pleased with the result. Selective vagotomy has theoretic advantages over truncal vagotomy and may avoid the possibility of postvagotomy diarrhea. Both truncal and selective vagotomy are in danger of being overshadowed by proximal gas tric vagotomy, a procedure that is now being evaluated prospective! y. The shortterm efficacy of proximal gastric vagotomy is satisfactory, but only long-term study will show the eventual role of this procedure in the operative therapy of duodenal ulcer. Special training in the performance of proximal gastric vagotomy is required to achieve favorable results. • Address reprint requests to Philip E. Donahue, MD, Department of Surgery, University of Illinois Abraham Lincoln School of Medicine, 840 S Wood St, Chicago, IL 60680.
References 1. Latarjet A: Resection des nerfs de l'estomac. Bull Acad Nat Med (Paris) 87:681, 1922 2. Dragstedt LR, Owens FM Jr: Supradiaphragmatic section of the vagus nerves in the treatment of duodenal ulcer. Proc Soc Exp Biol Med 53:152, 1943 3. Dragstedt LR: A concept of the etiology of gastric and duodenal ulcer (Caldwell lecture, 1955). Am J Roentgenol 75:219, 1956 4. Dragstedt LR. Woodward ER: Appraisal of vagotomy for peptic ulcer after seven years. JAMA 145:795, 1951
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5. Weinberg JA, Stempien SJ, Movius HJ, et al: Vagotomy and pyloroplasty in the treatment of duodenal ulcer. Am J Surg 92:202, 1956 6. Nyhus LM: Two decades of gastrointestinal research: A perspective. Am J Surg 131:3, 1976 7. Franksson C: Selective abdominal vagotomy. Acta Chir Scand 96:409, 1948 8. Burge HW: Vagal nerve section in chronic duodenal ulceration (Hunterian lecture, 5 Nov 1969). Ann R Coll Surg Engl 26:231. 1960 ....
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vagotomy 9. Griffith CA: Gastric vagotomy vs. total abdominal vagotomy. Arch Surg 81:781, 1960 10. Hendry WG: Vagotomy and pyloroplasty. ln Harkins HN, Nyhus LM (Editors): Surgery of the Stomach and Duodenum. Ed 2. Boston, Little, Brown & Co, 1969 Il. Kennedy T, Connell AM, Love AH. et al: Selective or truncal vagotomy? Five-year results of a double-blind, randomized, controlled trial. Br J Surg 60:944, 1973 12. Griffith CA: Selective gastric vagotomy. 1. Eliminating the occurrence of incomplete gastric vagotomy by refined techniques of total abdominal and selective gastric vagotomy. West J Surg Obstet Gynecol 70:107, 1962 13. ---:Selective gastric vagotomy. II. Eliminating undesirable sequelae of total abdominal vagotomy by selective gastric vagotomy. West J Surg Obstet Gynecol 70:175, 1962 14. Jackson RG: Anatomie study of the vagus nerves with a technique of transabdominal selective gastric vagus section. Arch Surg 57:333, 1948 15. Skandalakis JE, Rowe JS Jr, Gray SW, et al: Identification of vagal structures at the esophageal hiatus. Surgery 75:233, 1974 16. Griffith CA, Harkins HN: Partial gastric vagotomy: An experimental study. Gastroenterology 32:96, 1957 17. Holle F, Hart W: Forrn- und funktionsgerecht Operation. Langenbecks Arch Chir 309:205, 1965 18. Amdrup E, Jensen HE: Selective vagotomy of the parietal cell mass preserving innervation of the undrained antrum. Gastroenterology 59:522, 1970 19. Johnston D, Wilkinson A: Selective vagotomy with inner-
readysource AUDIOVISUALS
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vated antrum without drainage procedure for duodenal ulcer. Br J Surg 56:626. 1969 Grassi G: Selektive totale Vagotomie. In Burge H (Editor): Vagotomie. Stuttgart, German y, Georg Thieme Verlag, 1976, p 79 Kronborg 0, Mad sen P: A controlled randomized trial of highly selective vagotomy versus selective vagotomy and pyloroplasty in the treatment of duodenal ulcer. Gut 16:268, 1975 Goligher JC: A technique for highly selective (parietal cell or proximal gastric) vagotomy for duodenal ulcer. Br J Surg 61:337, 1974 Hallenbeck GA, Gleysteen JJ, Aldrete JA, et al: Proximal gastric vagotomy: Effects of two operative techniques on clinical and gastric secretory results. Ann Surg 184:435, 1976 Herrington JL, Sawyers JL: Proximal gastric vagotomy: Technique, indications, and results. Contemp Surg 9:57, 1976 Kusakari K, Nyhus LM, Gillison EW, et al: An endoscopie test for completeness of vagotomy. Arch Surg 105:386, 1972 Saik RP, Greenburg AG, Farris JM, et al: The practicality of the Congo red test, oris your vagotomy complete? Am J Surg 132:144, 1976 Burge H, Vane JR: Method of testing for complete nerve section during vagotomy. Br Med J 1:615, 1958 Kalahanis NG, Das Gupta TK, Nyhus LM: Neural control of blood flow in ga strie mucosa. Am J Surg 131 :86, 1976
D
VAGOTOMY
DO
Operations for Duodenal Ulcer Jesseph 60-min, :V4-in. or 2-in. U-matic cassette, brochure, catalog no. VC-2076 Source: Indiana University School of Medicine, 1100 W Michigan St, Indianapolis, IN 46202 Coat: Rentai preview, $25/wk; :V4-in., $125; 2-in., $350 Vagotomy: Truncal, Selective, or Parietal Cell Scott et al (panel discussion) Cassette, catalog no. 0230, $15 Duodenal Ulcer Dlsease Condon (Chairman) 9-hr postgraduate course, cassettes, catalog no. 0346, $65 Gastrolntestlnal Dlsease Sawyers (Chairman) 12-hr postgraduate course, cassettes, catalog no. 0359, $85 Source: ACS/Ciinitapes, 55 E Erie St, Chicago, IL 60611 Parietal Cell Vagotomy Nyhus 25-min 16-mm film, catalog no. DG-1169 Source: American Collage of Surgeons, Surgical Film Library, Davis & Geck Distributors, 1 Casper St, Danbury, CT 06810 Coat: $1 0, on loan
Vol. 62 • No. 4 • October 1977 • POSTORADUATE MEDICINE
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BOOKS Surgery of the Stomach and Duodenum Nyhus, Wastell (Editors), ed 3, 1977 Publlsher: Little, Brown & Co, Boston Vagotomie Burge et al, 1976 Publlsher: Georg Thieme Verlag, Stuttgart, Germany Vagotomy: Latest Advances wlth Specifie Reference to Gastrlc and Duodenal Ulcer Dlsease Holle, 1974 Publlsher: Springer-Verlag New York, lnc, New York CIBA Collection of Medical Illustrations Vol 3 DIgestive System. Part 1 : Upper Digestive Tract Netter (lllustrator), Oppenheimer (Editor), 3rd printing Publlsher: CIBA, Summit, NJ Elllson's Atlas of Surgery of the Stomach and Duodenum Carey, Albertin, 1971 Publlsher: The CV Mosby Co, St Louis
For information on how to use ReadySource. see page 143.
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ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Role of vagotomy in duodenal ulcer Philip E. Donahue, Alain J. Marrie, Randall J. Krystosek & Lloyd M. Nyhus To cite this article: Philip E. Donahue, Alain J. Marrie, Randall J. Krystosek & Lloyd M. Nyhus (1977) Role of vagotomy in duodenal ulcer, Postgraduate Medicine, 62:4, 156-167, DOI: 10.1080/00325481.1977.11714649 To link to this article: http://dx.doi.org/10.1080/00325481.1977.11714649
Published online: 07 Jul 2016.
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from the 61 st an nuai postgraduate medical assembly
role of vagotomy in duodenal ulcer Philip E. Donahue, Alain J. Marrie, Randall J. Krystosek, Lloyd M. Nyhus,
MD MD MD MD
University of Illinois at the Medical Center Chicago
Vagotomy is a dynamic, evolving therapeutic tool rather than the "simple" operation it is sometimes assumed to be. Postoperative ulcer recurrence remains a problem, and the development of a foolproof peroperative test for completeness of vagotomy will be welcome.
• The evolution of surgical vagotomy in the treatment of abdominal disease is of interest for ali practitioners of medicine. When first introduced, vagotomy (as total gastric vagotomy) was performed for widely disparate clinical syndromes ranging from tabetic crisis to gastric ulceration. 1 Early investigators suspected that section of the vagus nerves led to a decrease in gastric acid production (still the most desirable effect of vagotomy). The modern era was heralded by Dragstedt and Owens2 in 1943, wh en they reported the use of transthoracic truncal vagotomy for duodenal ulcer. The earl y success of this operation led to hopes that the definitive treatment of duodenal ulcer had been discovered, but subsequent difficulties with gastric stasis proved these hopes to be futile. Nonetheless, the place of vagotomy in the treatment of duodenal ulcer had been firmly established. (ln 1956, Dragstedt3 hypothesized that duodenal ulcer relates primarily to a derangement of neural control of gastric secretion, a view that continues to provide the best explanation for the pathophysiology of this type of ulcer.) Knowledge of the anatomy of the vagi facilitates an understanding of the different types of vagotomy now being do ne and the rationale for each. An anatomical description and sorne related surgical considerations are given on page 158.
Cllnlcal Applications
Truncal vagotomy-Following the realization that gastric stasis occurred after trun cal vagotomy in up to 50% of patients, pyloroplasty or gastrojejunostomy for stomach drainage was added to the procedure. 4 .s The combined procedure has been used to treat more duodenal ulcers than any other operation in history. Interestingly, both truncal vagotomy and gastroenterostomy, when first introduced, were thought to be superb treatments for duodenal ulcer. With long-term follow-up, however, it became clear that either procedure alone was inadequate. Long-term results of the combined procedure (though excellent for sorne groups) have likewise been somewhat disappointing, the ulcer recurrence rate being about 10% in most series and up to 25% in Presented in part by Dr Nyhus as the Aiton Ochsner Lecture.
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others. 6 The cause for the high rate of recurrence is most often incomplete vagotomy, for reasons related to the anatomie arrangement of the esophageal plexus and the main vagal trunks at the esophageal hiatus. The high incidence of recurrent ulcer is not the only disadvantage of truncal vagotomy. Others are the occurrence of postvagotomy diarrhea, possible dysfunction of the pancreas or gallbladder, and risks associated with surgieal drainage of the stomach. Factors that have made the vagotomy-drainage procedure so attractive to surgeons are the low surgical mortality and the relative ease and rapidity of performance. The combined procedure bas ''legitimized'' surgie al treatment of duodenal ulcer, since it avoids the many complications of subtotal gastrectomy (high mortality, poor nutrition, high incidence of severe dumping syndrome) and can be readily performed by ali general surgeons. Selective vagotomy-Selective gastric vagotomy was developed in an attempt to achieve complete gastric denervation without damaging vagal nerve fibers running to other abdominal organs. Though frrst investigated by Wertheimer and Latarjet in 1922, the technique was not revived until the late 1940s. At that time, it was thought that if the pyloric branches of the gastrohepatic vagi were spared, the stomach might empty normally7; wh en gas tric emptying remained unsatisfactory, selective vagotomy was temporarily abandoned. The concept of adding a gastric drainage procedure to a complete vagotomy bad not yet been formulated. In 1960, Burge8 and Griffith9 independently reported the technique of selective vagotomy wtth antrectomy (removal of 25% to 40% of the stomach, including the pylorus)
for duodenal ulcer. The immediate reason for initiating these more recent investigations was to defme a madel of gastric denervation that could avoid the sequelae of truncal vagotomy (mainly diarrhea). White in many instances postvagotomy '' diarrhea'' consists merely of a change in frequency or in consistency of the bowel movement and as such causes little discomfort, in 1% to 2% of patients it is almost incapacitating. 10·11 In these patients, the propensity for unexpected and urgent bowel motions (often so sudden that incontinence results) may be so unnerving that any social interaction is feared. Therefore, an operation that minimizes this unpleasant syndrome would be advantageous. Of importance is the question ofhow effectively the stomach is denervated by the selective technique. If, as was thought, the vagi comprise two trunks at the esophageal hiatus and if the two trunks con tain ali of the gas tric vagi, then section of the trunks necessarily is a complete gastrie vagotomy. The selective technique, when viewed in the light of this assumption, can at most accomplish what truncal nerve division theoretieally assures. Such reasoning, though fallacious, still bas appeal to many surgeons. The crux of the problem lies in the anatomie distribution of the vagi, the manner in whieh the esophageal vagal plexus is reconstituted above the esophageal hiatus, and the possible earl y branching of the main vagal trunks proximal to the usual point of nerve transection in truncal vagotomy. Since the vagal system bas no embryologie or anatomie relation with the diaphragm, the vagi at the esophageal hiatus may exist in the form of an esophageal plexus, trunks, or truncal diviston12·13; a vagotomy procedure that aims
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anatomy of the vagi and related surgical considerations Anatomy•
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There are two main vagal trunks, the anterior (left) and the posterior (right). They derive from the plexus of nerves surrounding the esophagus in the thorax. Cross-sectional studies of the upper abdomen rarely show only two trunks; instead, two to seven nerves have been found. This is due to the existence of communicating branches between the trunks and of early gastric branches going directly to the stomach.
Anterior Trunk This trunk (figure 1) is single in only one third of cases; more often, it is plexiform. lt is usually situated on the anterior wall of the esophagus bene ath the peritoneum overlying the gastroesophageal junction. Sometimes (rarely) it is situated at the left margin of the esophagus. The anterior trunk gives rise to two kinds of branches: Gastrohepatic-The gastrohepatic branches (Burge gastrohepatic plexus) are usually multiple but may be single. Coming from the right margin of the anterior trunk, just above the cardia, these nerves cross from left to right across the most cephalad portion of the lesser omentum to join the transverse fissure of the liver. At that point, a nerve with a recurrent course from the hepatic pedicle to the superior margin of the duodenum is seen. lt is called the Latarjet-pyloroduodenal pedicle and is constant anatomically. Gas tric (two types)- The esophagofundic branches, four to five in number, course directly to the lower esophagus and fundus of the stomach. The second gastric branch (first described by Wertheimer) is the principal anterior nerve of the lesser curvature. This large nerve is the major continuation of the anterior vagal trunk below esophagogastric branches, and is known as the nerve of Latarjet. lt descends alongside the lesser curvature, 2 cm to the right of it. From its left margin arise four to five gastric branches which cross directly to the stomach. The nerve of Latarjet terminales on the superior margin of the antrum, about 5 to 7 cm from the pylorus. The two or three terminal ramifications (the crow's foot) innervate the anterior wall of the antrum but never join the pylorus; recurrent branches from the more proximal ramifications of the crow's foot may innervate the distal corpus. Posterior Trunk The posterior trunk (figure 2) is usually situated behind the right margin of the esophagus; it may be
•o,"cription ha":J largd) on 'tudic' made by Wcnhcimcr (a 'tude ni of L~tarJdJ 111 1Y22 'upplcmcntcJ by rcu:nt di"c•t·tion' c~rncd out h) one of u' IR .J. K.) in the an~lomy lahoratory.
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located more posteriorly on the right crus of the diaphragm. This trunk also gives rise to two branches: Celiac-This branch arises from the right margin and goes to the ce liac plexus, innervating the en tire digestive tract. One branch may travel through the celiac plexus and then behind the first portion of the duodenum (along the right gastroepiploic artery) to supply the parasympathetic innervation of the gastric greater curvature. This is called the gastroepiploic pedicle and sometimes also the pedicle of the greater curvature. Gastric (two types)-Esophagogastric branches originale from the left margin below the main celiac branch and are four to five in number. The second branch, the principal posterior nerve of the lesser curvature, is symmetric with the principal anterior nerve. (See figure 1.) lt descends along the lesser curvature and ends on the superior margin of the antrum without joining the pylorus. From its left margin arise four to five branches which innervate the corpus of the stomach.
Direct Gastric Branches Branches of esophageal vagal origin, arising either from the plexus or early from one of the trunks, cross the diaphragm directly and then join the fundus of the stomach. Most commonly recognized are early branches of the anterior or posterior trun k. ln approximately 10% of specimens, such direct gastric branches arise from the anterior trunk; however, the posterior trunk routinely gives rise to one or several direct gastric branches which cross behind the esophagus to join the posterior fundus (figure 2). Such branches are called criminal because they are likely to be forgotten or missed during operative dissection.
Surglcal Considerations · 1. Section of the vagal trunks above the gastric branches accomplishes parasympathetic denervation of the stomach and of the entire digestive tract (truncal vagotomy) (figure 3). 2. Section of the vagal trunks immediately distal to the gastrohepatic branch of the anterior vagus and the celiac branch of the posterior vagus, with division of esophagogastric branches, direct gastric branches (anterior and posterior), and nerves of Latarjet, accomplishes selective denervation of the stomach (selective vagotomy) (figure 4). 3. Section of the esophagogastric branches, the direct gastric branches, and the anterior and posterior gastric branches of the principal nerves of the lesser curvature (sparing the n'3rves of Latarjet), effects selective denervation of the fundus but not of the antrum (proximal gastric vagotomy) (figure 5). 4. lncomplete vagotomy may result if care is not taken to find ali branches to be sectioned in the chosen procedure.
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----li
Anterior vagus Posterior vagus -
Criminal nerve /
1
Posterior vagus "---.
i
!
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Ce liac branch
L____
--- _ _ _ _ _ _ _ _ j
Figure 1. Anterior (left) vagus nerva is depicted as being thick for ease of visualization; in reality it may be thin and difficult to recognize. If so, traction on the lasser curvature of the stomach tautens the nerve and aids in its identification. r------------------
Poste ri or vag us
--..:.--
....... __Gas~r~e~~lo~-pe-dic~~--__j \
Figure 2. Posterior (right) vagus nerve is usually much thicker than the anterior vagus. Note that first branches of the nerva could be missed if the left margin of the gastroesophageal junction were not carefully examined. Highest branch depicted is "criminal" nerve (direct gastric branch).
Figure 3. ln carrying out truncal vagotomy, a careful search for small direct branches must be made. They will be found in a high percentage of cases. Their division can best be insured by baring the esophagus of ali surrounding tissue at the point where the main vagal trunks are divided.
---~
-- Anterior vagus
/ Anterior vagus
t
Posterior vag us
Criminal nerve
i !
Ce liac
'
1
1
!
1
l__·- -
_j
Figure 4. Selective vagotomy spares vagal fibers of the hepatic and celiac plexuses. Preferred method of assuring division of ali vagal branches to the stomach is to clear lower 5 to 6 cm of the esophagus of ali surrounding tissues and to section main trunks distal to the hepatic and celiac branches.
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L_
Figure 5. Proximal gastric vagotomy attempts to denervate ali acid-secreting portions of the stomach, leaving the distal motor segment (antrum) innervated. Critical portions of dissection involve the gastroesophageal junction, which must be bared for 5 to 6 cm to assure division of ali criminal branches, and identification of distal extent of the acid-secreting tissues which should be denervated. ..,.
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vagotomy ............................................_
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Just as effective techniques for truncal and selective vagotomy had to be dlscovered and dlssemlnated, so also must techniques for proximal gastrlc vagotomy.
at mere identification and section oftwo vagal "nerves" risks incomplete section. 14 •15 Selective vagotomy accomplishes section of the vagal nerves at the point where their relation to the stomach is clear and their complete division can be more readily assured. However, care must be taken to find ali gastric branches, especialiy to the left margin of and behind the esophagus, to avoid incomplete section. In experimental and clinical models comparing truncal and selective vagotomy to determine which procedure results in greater reduction of acid secretion and ulcer recurrence, selective vagotomy bas often fared better. For this reason, it is the recommended procedure for elective vagotomy. Pyloroplasty or gastroenterostomy, however, must also be performed to aliow for gastric atony after division of motor nerves to the antrum. Proximal gas tric vagotomy-The next phase in the evolution of vagotomy for duodenal ulcer began in 1957, when proximal gastric vagotomy (also known as parietal celi vagotomy, selective proximal vagotomy, and highly selective vagotomy) was performed. 16 The desirable features of the operation ali relate to preservation of antral innervation. Since a stomach with antral innervation empties normally, no drainage procedure is required. Other beneficiai aspects are avoidance of contamination of the operative field by gastroduodenal contents, absence of adverse sequelae of vagotomy (diarrhea) and drainage procedures (dumping syndrome and reflux alkaline gastritis), and most important, almost zero chance of mortality. The frrst report of proximal gastric vagotomy carried out in a series of patients appeared in 1964_17 The procedure was combined with a "form and function" pyloroplasty, ie, pyloroplasty tailored to the presence or absence of scarring about the pylorus. In 1969, Amdrup and colleagues18 and Johnstan and Wilkinson19 began performing proximal gastric vagotomy without a drainage procedure, and since then the operation bas been done in over 5,000 patients. The procedure bas fulfilled ali expectations in terms of low mortality and absence of undesirable
sequelae--except for the recurrence of ulcer. How great is the risk of ulcer recurrence? The recurrence rate bas been reported to be 2% to 4% in the most favorable series and 20% to 28% in the least favorable. These are relatively short-term results, however. We remember with sorne trepidation that gastroenterostomy alone or truncal vagotomy with drainage for duodenal ulcer achieved excellent results initially, but long-term foliow-up showed a relatively high incidence of recurrence. It remains to be seen whether the his tory of proximal gastric vagotomy will follow the same course. If this procedure is successful in controliing duodenal ulcer, then perhaps the ideal operation will have been discovered. Ulcer recurrence is certainly a most serious complication, but the possibility must be considered in the context of an operation that bas al most no morbidity or mortality. Furthermore, if reoperation is necessary, surgery can be performed in an almost virgin abdomen. Future candidates for proximal gastric vagotomy will in ali probability have to decide what chance of recurrent ulcer they are willing to risk to a void the unpleasant side effects of the more conventional vagotomy procedures, particularly truncal vagotomy. The wide variance in ulcer recurrence rates after proximal gastric vagotomy in different series of patients appears to be due to differences in operative technique. Just as effective techniques for truncal and selective vagotomy bad to be discovered and disseminated, so also must techniques for this type of vagotomy. Recurrence after truncal vagotomy usually relates to vagal fibers left intact; the same may be true in proximal gastric vagotomy. The anatomie distribution of vagal fibers at the cardia of the stomach may explain this. 1t bad been thought that the vagal fibers to the stomach ali coalesced at the lesser curvature of the stomach, and that denervation of the acid-secreting cells could be accomplished by surgie al dissection of ali vagal fibers penetrating the stomach along the lesser curvature. This approach failed to adequately denervate the fundus of the stomach, because gastric
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vagotomy ..................................................... . Dr Donahue is assistant professer, department of surgery, University of Illinois Abraham Lincoln School of Medicine, Chicago. Dr Marrie collaborated with the other authors while on an extended visit to the University of Illinois. He is now assistant clinic chief, Center Hospital of the University of Strasbourg, Strasbourg, France. Dr Krystosek is a fellow in surgical anatomy, University of Illinois Hospital, Chicago. Dr Nyhus is Warren H. Cole Professer, and head, department of surgery, University of Illinois Abraham Lincoln School of Medicine.
Philip E. Donahue
branches may arise from the posterior vagus at a high leve! and enter the fundus of the stomach at the left side of the cardioesophageal junction (the "criminal" branches20 ). Lack of sufficient dissection appears to account for the initially high recurrence rates reported in sorne series. 21 It now appears that not only must the left side of the cardia be bared, but that the distal 5 to 7 cm of esophagus must be completely dissected from surrounding tissues to insure adequate denervation.22 This concept has received support by Hallenbeck and co-workers, 23 who modified their technique for proximal gastric vagotomy for duodenal ulcer when their recurrence rate for proved or suspected ulcer was alarmingly high (25% ). By incorporating meticulous and extensive periesophageal dissection, they had on! y one ulcer recurrence in 17 patients recent! y operated on. 23 A more radical approach to periesophageal dissection has been proposed by Herrington and Sawyers. 24 They advocate circumferential division of ali esophageal muscle layers Iying just above the gastroesophageal junetien, th us insuring division of ali of the "little nerve fibrils'' passing through the esophagus to the stomach. At the completion of this maneuver, the nasogastric tube in the esophagus can be seen through the denuded, transparent mucosa. This seems to us to be a possibly dangerous and probably unnecessary procedure. An additional consideration is the question of how far distally the nerves should be dissected. Two approaches are currently in use.
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In the anatomie approach, the major nerves of the lesser curvature (nerves of Latarjet) are spared, leaving 5 to 8 cm of the distal stomach innervated, while in the physiologie approach, a peroperative test of acid secretion is used to define the extent of the antrum (since the acid-secreting portions of the stomachthe fundus and the corpus-are the only portions intentionally denervated by proximal gastric vagotomy). While the anatomie and physiologie boundaries of acid-secreting mucosa and antral "pump" may coïncide, the matter is still unsettled, and further information will certainly be necessary before any precise approach is validated. We have used the transendoscopic Kusakari test25 •26 to define the distal extent of acid-secreting mucosa.
Tests for Completeness of Vagotomy No matter which type of vagotomy is performed, the question of completeness remains, since incomplete section accounts for the majority of ulcer recurrences. How is the completeness of vagotomy determined? A foolproof peroperative test would resolve this vexing problem and minimize the risk of performing an incomplete vagotomy at the first operation. Techniques currently used include the electrical stimulation test devised by Burge and Vane, 27 gastrotomy and pH probe measurements, and transendoscopic tests. 25 .2 6 Varying results from these have been reported, and an efficient, noncumbersome, peroperative test of vagal integrity remains to be developed. Theoretlcal Aspects of Vagotomy In the past, the beneficiai effects of vagotomy were thought to result from acetylcholine deficiency in cells previously innervated by the vagus nerves. Supporting this concept are the facts that vagotomy decreases basal and stimulated secretion of acid and th at it abolishes secretion of acid in response to cephalic vagal stimulation, such as occurs with 2-deoxy-o-glucose and from insulin hypoglycemia. However, the precise outcome of va-
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............................................... vagotomy gotomy may represent more than loss of parasympathetic stimulation. Ultrastructural studies of gastric mucosal cells after vagotomy show changes in sympathetic as weil as in parasympathetic nerve terminais, leading to speculation about the role (if any) of such nerve fibers in normal gastric function. Results of other investigations with antagonists of sympathetic nerve function support the thesis that the sympathetic system is intimately involved in normal gastric physiology.2s With increasing awareness of the complex dynamics of gastric secretion, other aspects of vagal function and structure are being considered in assessing the effects of vagal innervation. There are very few "ali or none" situations concerning gastric secretion-in most experimental models, the effects of hormones, neural influences, and endogenous mucosal secretion are combined. For example, the relation between an endocrine cell population in the gas tric mucosa and observed secretory effects is only beginning to be elucidated. Morphologie observation of autonomie nerve fibers within the vagal nerves may yield a final definition of the way in which the gastric mucosa synthesizes information and "decides" at a given time whether gastric secretion should be turned on or off. On the clinical side of the picture, the dramatic effects on inhibition of acid secretion of the histamine H2-receptor antagonists and prostaglandins may be the beginning of the end of "chronicity" of acute duodenal ulcer. Of course, ali conclusions reached in this regard
are at best preliminary and require meticulous long-term study.
Conclusion lt is clear that vagotomy is a dynamic, evolving therapeutic tool and not the unchanging •·simple'' operation it is sometimes assumed to be. Many questions about the procedure, its effects, and the best ways to use it to achieve maximum patient benefit remain to be answered. For the present, a patient who requires surgery for ulcer should receive the operation which is best suited for the disease process and most familiar to the surgeon. There should be no misunderstanding about the fact that truncal vagotomy is an extremely useful operative procedure for duodenal ulcer and that most patients who undergo this procedure are quite pleased with the result. Selective vagotomy has theoretic advantages over truncal vagotomy and may avoid the possibility of postvagotomy diarrhea. Both truncal and selective vagotomy are in danger of being overshadowed by proximal gas tric vagotomy, a procedure that is now being evaluated prospective! y. The shortterm efficacy of proximal gastric vagotomy is satisfactory, but only long-term study will show the eventual role of this procedure in the operative therapy of duodenal ulcer. Special training in the performance of proximal gastric vagotomy is required to achieve favorable results. • Address reprint requests to Philip E. Donahue, MD, Department of Surgery, University of Illinois Abraham Lincoln School of Medicine, 840 S Wood St, Chicago, IL 60680.
References 1. Latarjet A: Resection des nerfs de l'estomac. Bull Acad Nat Med (Paris) 87:681, 1922 2. Dragstedt LR, Owens FM Jr: Supradiaphragmatic section of the vagus nerves in the treatment of duodenal ulcer. Proc Soc Exp Biol Med 53:152, 1943 3. Dragstedt LR: A concept of the etiology of gastric and duodenal ulcer (Caldwell lecture, 1955). Am J Roentgenol 75:219, 1956 4. Dragstedt LR. Woodward ER: Appraisal of vagotomy for peptic ulcer after seven years. JAMA 145:795, 1951
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5. Weinberg JA, Stempien SJ, Movius HJ, et al: Vagotomy and pyloroplasty in the treatment of duodenal ulcer. Am J Surg 92:202, 1956 6. Nyhus LM: Two decades of gastrointestinal research: A perspective. Am J Surg 131:3, 1976 7. Franksson C: Selective abdominal vagotomy. Acta Chir Scand 96:409, 1948 8. Burge HW: Vagal nerve section in chronic duodenal ulceration (Hunterian lecture, 5 Nov 1969). Ann R Coll Surg Engl 26:231. 1960 ....
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vagotomy 9. Griffith CA: Gastric vagotomy vs. total abdominal vagotomy. Arch Surg 81:781, 1960 10. Hendry WG: Vagotomy and pyloroplasty. ln Harkins HN, Nyhus LM (Editors): Surgery of the Stomach and Duodenum. Ed 2. Boston, Little, Brown & Co, 1969 Il. Kennedy T, Connell AM, Love AH. et al: Selective or truncal vagotomy? Five-year results of a double-blind, randomized, controlled trial. Br J Surg 60:944, 1973 12. Griffith CA: Selective gastric vagotomy. 1. Eliminating the occurrence of incomplete gastric vagotomy by refined techniques of total abdominal and selective gastric vagotomy. West J Surg Obstet Gynecol 70:107, 1962 13. ---:Selective gastric vagotomy. II. Eliminating undesirable sequelae of total abdominal vagotomy by selective gastric vagotomy. West J Surg Obstet Gynecol 70:175, 1962 14. Jackson RG: Anatomie study of the vagus nerves with a technique of transabdominal selective gastric vagus section. Arch Surg 57:333, 1948 15. Skandalakis JE, Rowe JS Jr, Gray SW, et al: Identification of vagal structures at the esophageal hiatus. Surgery 75:233, 1974 16. Griffith CA, Harkins HN: Partial gastric vagotomy: An experimental study. Gastroenterology 32:96, 1957 17. Holle F, Hart W: Forrn- und funktionsgerecht Operation. Langenbecks Arch Chir 309:205, 1965 18. Amdrup E, Jensen HE: Selective vagotomy of the parietal cell mass preserving innervation of the undrained antrum. Gastroenterology 59:522, 1970 19. Johnston D, Wilkinson A: Selective vagotomy with inner-
readysource AUDIOVISUALS
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vated antrum without drainage procedure for duodenal ulcer. Br J Surg 56:626. 1969 Grassi G: Selektive totale Vagotomie. In Burge H (Editor): Vagotomie. Stuttgart, German y, Georg Thieme Verlag, 1976, p 79 Kronborg 0, Mad sen P: A controlled randomized trial of highly selective vagotomy versus selective vagotomy and pyloroplasty in the treatment of duodenal ulcer. Gut 16:268, 1975 Goligher JC: A technique for highly selective (parietal cell or proximal gastric) vagotomy for duodenal ulcer. Br J Surg 61:337, 1974 Hallenbeck GA, Gleysteen JJ, Aldrete JA, et al: Proximal gastric vagotomy: Effects of two operative techniques on clinical and gastric secretory results. Ann Surg 184:435, 1976 Herrington JL, Sawyers JL: Proximal gastric vagotomy: Technique, indications, and results. Contemp Surg 9:57, 1976 Kusakari K, Nyhus LM, Gillison EW, et al: An endoscopie test for completeness of vagotomy. Arch Surg 105:386, 1972 Saik RP, Greenburg AG, Farris JM, et al: The practicality of the Congo red test, oris your vagotomy complete? Am J Surg 132:144, 1976 Burge H, Vane JR: Method of testing for complete nerve section during vagotomy. Br Med J 1:615, 1958 Kalahanis NG, Das Gupta TK, Nyhus LM: Neural control of blood flow in ga strie mucosa. Am J Surg 131 :86, 1976
D
VAGOTOMY
DO
Operations for Duodenal Ulcer Jesseph 60-min, :V4-in. or 2-in. U-matic cassette, brochure, catalog no. VC-2076 Source: Indiana University School of Medicine, 1100 W Michigan St, Indianapolis, IN 46202 Coat: Rentai preview, $25/wk; :V4-in., $125; 2-in., $350 Vagotomy: Truncal, Selective, or Parietal Cell Scott et al (panel discussion) Cassette, catalog no. 0230, $15 Duodenal Ulcer Dlsease Condon (Chairman) 9-hr postgraduate course, cassettes, catalog no. 0346, $65 Gastrolntestlnal Dlsease Sawyers (Chairman) 12-hr postgraduate course, cassettes, catalog no. 0359, $85 Source: ACS/Ciinitapes, 55 E Erie St, Chicago, IL 60611 Parietal Cell Vagotomy Nyhus 25-min 16-mm film, catalog no. DG-1169 Source: American Collage of Surgeons, Surgical Film Library, Davis & Geck Distributors, 1 Casper St, Danbury, CT 06810 Coat: $1 0, on loan
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BOOKS Surgery of the Stomach and Duodenum Nyhus, Wastell (Editors), ed 3, 1977 Publlsher: Little, Brown & Co, Boston Vagotomie Burge et al, 1976 Publlsher: Georg Thieme Verlag, Stuttgart, Germany Vagotomy: Latest Advances wlth Specifie Reference to Gastrlc and Duodenal Ulcer Dlsease Holle, 1974 Publlsher: Springer-Verlag New York, lnc, New York CIBA Collection of Medical Illustrations Vol 3 DIgestive System. Part 1 : Upper Digestive Tract Netter (lllustrator), Oppenheimer (Editor), 3rd printing Publlsher: CIBA, Summit, NJ Elllson's Atlas of Surgery of the Stomach and Duodenum Carey, Albertin, 1971 Publlsher: The CV Mosby Co, St Louis
For information on how to use ReadySource. see page 143.
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