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Clinical trial of vagotomy and pyloroplasty in the treatment of benign gastric ulcer
Clinical Trial of Vagotomy and Pyloroplasty in the Treatment of Benign Gastric Ulcer JOHN L. SAWYERS, MD, Nashville, H. W. SCOTT, Jr, MD, Nashville,
CHARLES GRAHAM, MD, Nashville,
The standard operation for benign gastric ulcer in the Vanderbilt Medical Center has been partial gastric resection usually limited to the distal half of the stomach, being certain that the antrum was removed along with the gastric ulcer. Gastrointestinal continuity is usually re-established by means of a Billroth I gastroduodenostomy. Since threefourths or more of benign gastric ulcers occur in the prepyloric area or along the lesser curvature of the stomach, it has been possible to perform this operation without difficulty in most patients. The Shoemaker modification of the Billroth I operation permits excision of gastric ulcers on the lesser curvature of the stomach, except for those in the cardia, while preserving sufficient gastric reservoir to prevent anemia and nutritional difficulties. A review of 140 patients with benign gastric ulcer treated by resection revealed a good to excellent result in more than 90 per cent of the patients with a twelve year follow-up period. The mortality was 2.8 per cent. The four deaths occurred in patients who had bled massively and underwent emergency operation [ I]. Recurrent ulcer developed in four patients (2.8 per cent), none of whom had an associated duodenal ulcer. These patients had resection combined with vagotomy. Because of this experience, we have added vagotomy to the operation in recent years. The findings of Ferguson [Z] and Oberhelman and Dragstedt [3] that complete gastric vagotomy reduces the sensitivity of the parietal cells to humeral agents lends support to the concept of vagotomy in the management of benign gastric ulcer. When Farris and Smith [4] reported to the American Surgical Association in 1963 satisfactory results in fifteen patients with benign gastric ulcers managed by vagotomy and pyloroplasty
From the Department Nashville, Tennessee Presented at the gery of the Alimentary
Volume
121,
of Surgery, Vanderbilt University Medical Center, 37203. Eleventh Annual Meeting of the Society for Sur. Tract, Chicago, Illinois, June 20 and 21, 1970.
February 1971
Tennessee
Tennessee Tennessee
with the gastric ulcer left in situ, we began to treat a few patients by this method. Since clinical studies both support and reject the effectiveness of vagotomy and pyloroplasty for the management of gastric ulcer in the absence of associated duodenal ulcer or hypersecretion, we decided to make a clinical study of vagotomy and pyloroplasty in the treatment of benign gastric ulcer in patients seen at the Vanderbilt University Medical Center. Clinical Study
A total of forty-eight patients with benign gastric ulcer and no roentgenologic or operative finding of associated duodenal ulcer have been managed by truncal vagotomy and pyloroplasty performed in a one layer suture closure as described by Weinberg [5]. Gastric ulcers were biopsied by the four quadrant technic and immediate cryostat pathologic examination performed to rule out malignancy (Figure 1.) In no patient has gastric carcinoma been seen. The patients can be grouped into three categories: group I includes twenty-two patients having elective operation for intractable gastric ulcer; group II includes eighteen patients having emergency operation for massive bleeding from a gastric ulcer; and group III is comprised of eight patients who had been on ulcerogenic drugs (aspirin, reserpine, and/or steroids) and who had an emergency operation for massive bleeding. No patient with the so-called “stress ulcer,” ie, acute gastric ulceration developing after trauma or major operation, is included in this study. In group I patients, who underwent elective operation, there were nine men and thirteen women with an age range from thirty to eighty-four years, averaging 55.7 years. Only three of these patients had multiple gastric ulcers. The remainder had single gastric ulcers located in the prepyloric region in two patients, in the antrum in ten, in the body in four, and in the fundus in three. Group II patients, who had an emergency operation for massive bleeding, ranged in age from twenty to 119
Sawyers, Scott, amndGraham
Vagotofny
The operation Figure 1. open biopsy of the gastric layer pyloroplasty.
used in this ulcer, truncal
study consisted of vagotomy, and one
eighty-four years, with an average of fifty-one years. There were fourteen men and four women. Two patients had multiple ulcers whereas the rest had single ulcers located as follows: prepyloric region, two patients ; antrum, five ; the body, four ; and the fundus, five. Group III patients, who had emergency operation for hemorrhage and were on ulcerogenic drugs, ranged in age from fortyfour to ninety-one years. There were five men and three women. Four patients had multiple ulcers located in the body or fundus, and four had single ulcers which were all in the fundic area. Results
Seventeen of the twenty-two patients in group who were treated for intractable gastric ulcer by elective operation, have been judged to have had good to excellent results on follow-up studies for up to 61/s years (average three years). One patient has had only a fair result because of moderate dumping symptoms persistent at follow-up to sixty-four months. Six of the patients with satisfactory results have occasional mild dumping symptoms which are easily controlled by dietary measures. No serious nutritional problems or anemia have occurred. There was no operative mortality in this group. In four patients (18 per cent) in group I recurrent gastric ulcer developed at ten, sixteen, thirtyseven, and fifty months after operation. Only one of these patients was found to have an incomplete vagotomy by the insulin-hypoglycemia (Hollander) test. Reoperation with 40 per cent distal gastrectomy has been necessary in two patients. One refused reoperation despite roentgenographic evidence of recurrent ulcer and a bleeding episode requiring transfusion of 2,000 cc of blood. He was doing well when last seen forty-nine months after operation. The other patient died of massive upper gastrointestinal bleeding sixteen months after operation. At autopsy a recurrent gastric ulcer was I,
120
found in the fundus of the stomach. Anatomic dissection showed no evidence of residual vagal fibers to the stomach and no gastric outlet obstruction. The results in the patients in group II who had vagotomy with pyloroplasty as an emergency operation for massive bleeding from a gastric ulcer were better. Sixteen of eighteen patients (89 per cent) have had good or excellent results with the follow-up period to five years (average three years). There was one operative death in a man who died thirty-two days after operation as a result of clostridial infection of the abdominal wall. At autopsy a superficial gastric ulcer was found near the cardia in the region of his original gastric ulcer. In one patient recurrent gastric ulcer developed in the antrum two years after operation. The ulcer has been demonstrated on upper gastrointestinal x-ray study and manifested by bleeding. The patient is being treated by nonoperative measures, but against surgical advice. One patient in this group had positive results on the Hollander test but is asymptomatic and is considered to have an excellent result. No anemia or nutritional problems have occurred. Two patients have mild dumping symptoms and three patients have mild, intermittent diarrhea but all are satisfactorily controlled by dietary measures. Unsatisfactory results were obtained in the eight patients in group III who underwent operation for massive bleeding and who had been on ulcerogenic drugs, either aspirin, reserpine, and/ or steroids. Only one patient is living with a satisfactory result without reoperation. This patient habitually took aspirin but has now discontinued ingestion of salicylates. Three operative deaths occurred in this group. One patient died from pulmonary embolus and two had rebleeding while in the hospital. One of the two with rebleeding died without reoperation ; the other had gastric resection, which controlled further bleeding, but died of pulmonary complications. Recurrent ulcers have developed in two patients within eighteen months. One has had subtotal resection, and is doing well. The other is under medical treatment with consideration for reoperation. Two patients had late deaths at three an a half and five months after operation from associated cardiovascular disease. The average age in this group was seventy years. Comments
Recent reported clinical results of vagotomypyloroplasty in the treatment of gastric ulcer are shown in Table I. In addition, Woodward has warned of the dangers of pyloroplasty for the treatment of gastric ulcer and reported four patients with recurrent gastric ulcer [11]. He implies The American Journal of Surgery
Vagotomy TABLE
I
Reported Experience with VagotomyPyloroplasty for Gastric Ulcer
Author
Patients
Operative Mortality (per cent)
Dorton [6], 1966 Farris and Smith [7], 1967 Kraft [8], 1968 Stemmer et al [9], 1968 McNeil1 et al [lo], 1969 Present study
30 34 70 34 33 48
7 0 ? 3 3 8
Recurrence (per cent) 7 0 4 38 3 15
that the one layer Weinberg pyloroplasty is not a good drainage procedure and that antral stasis with increased gastrin production led to recurrent gastric ulceration in his patients. Zahn et al [12]. however, did not find evidence of gastric retention on routine gastrointestinal roentgenograms or barium motor meal studies in their postoperative patients. There was a 40 per cent incidence of recurrent gastric ulcer in thirty-eight patients in their series treated by drainage procedures with or without vagotomy, and Zahn et al stated that “it is difficult to explain the recurrence of gastric ulceration after vagotomy-pyloroplasty on the basis of antral stasis or incomplete vagotomy.” Lawson and Dragstedt [13] have shown on the basis of experimental studies in the dog that vagotomy-pyloroplasty results in an accentuated gastric phase of acid secretion. They postulate that although vagotomy-pyloroplasty seems adequate to control the ulcer diathesis in duodenal ulcer patients who have hypersecretion secondary to the cephalic phase of acid secretion, it is doubtful if vagotomy-pyloroplasty will protect against ulcer in patients with gastric ulcer who already have an accentuated gastric phase as the basic defect. Amdrup [1.4] prefers antral resection rather than a drainage procedure for patients with gastric ulcer. He sees no reason for those patients to have a pyloroplasty, much less vagotomy. Elderly patients with gastric ulcer usually have atrophic changes in the gastric mucosa, low response to an augmented histamine test, and evidence of reduced function of their parietal cell mass. In these patients, reduced parietal cell acid secretion with consequent rise in pH in the stomach may stimulate the antrum to a constant state of hyperfunction in an attempt to maintain a pH of 2.5 to 3. Amdrup believes that this theory explains why hyperfunction of the antrum is ulcerogenic and why antrectomy is the preferred operation in the patient with a gastric ulcer. It is important to differentiate between the types of gastric ulcers. The results of treatment of gastric “stress ulcers” and steroid-induced ulcers should not be compared with the solitary Volume 121, February 1971
and Pyloroplasty
for Benign
Gastric
Ulcer
gastric ulcer secondary to antral hyperfunction. If we eliminate the eight patients on ulcerogenic drugs from our study, there would be forty patients managed by vagotomy-pyloroplasty with an ulcer recurrence rate of 12.5 per cent. Because of this high recurrence we believe that vagotomy-pyloroplasty should be reserved for the elderly, poorrisk patient requiring emergency operation for bleeding if he has not been on ulcerogenic drugs as steroids, reserpine, or phenylbutazone. Vagotomypyloroplasty is not as satisfactory as antrectomy and vagotomy for managing the intractable benign gastric ulcer. Summary
A clinical trial of vagotomy and pyloroplasty in the treatment of benign gastric ulcer was performed in forty-eight patients. The incidence of recurrent gastric ulcers was 15 per cent. The results were satisfactory in patients undergoing emergency operation for massive bleeding from a gastric ulcer if the patient had not been on ulcerogenic drugs. However, the operation has not been as satisfactory as antral resection for the management of intractable gastric ulcer. References 1. Adams JE, Sawyers JL, Classen KL, Scott HW Jr: Man-
2.
3.
4.
5. 6.
agement of gastric ulcer. Rocky Mountain Med J 56: 81, 1959. Ferguson DJ: The antral phase of gastric secretion before and after vagotomy: experiments on gastric pouch dogs. Surgery-33: 352, 1953. Oberhelman HA Jr. Dragstedt LR: Effect of vagotomy on gastric secretoj response to histamine.-Proc -Sot Exper Viol Med 67: 336, 1948. Farris JM, Smith GK: Treatment of gastric ulcer (in situ) by vagotomy and pyloroplasty: a clinical study. Ann Surg 158: 461, 1963. Weinberg JA: Pyloroplasty and vagotomy for duodenal ulcer. Curr Probl Surg April, 1964. Dot-ton HE: Vagotomy, pyloroplasty, and suture for bleeding gastric ulcer. Surg Gynec Obstet 122: 1015,
1966. 7. Farris JM, Smith 8.
9.
10.
11.
GK: Quoted in Welch CE, Burke JF: Gastric ulcer reappraisal. Surgery 65: 708, 1969. Kraft RO: In discussion of Stemmer, ‘Zahn, Horn, and Connolly Arch Surg 96: 586, 1968. Stemmer EA, Zahn RL, Horn LW, Connolly JE: Vagotomy and drainage procedure for gastric ulcer. Arch Surg 96: 586, 1968. McNeil1 AD, McAdam WAF, Hutchison JSF: Vagotomy and drainage in the treatment of gastric ulcer. Surg Gynec Obstet 128: 91, 1969. Woodward ER, Eisenberg MM, Dragstedt LR: Recurrence of eastric ulcer after pyloroplasty. Amer J Surgery
113: j, 1967. 12. Zahn RL, Stemmer
EA, Horn LW, Connolly JE: Delayed recurrence of gastric ulcer following vagotomy and drainage procedures. Amer Surg 34: 757, 1968. 13. Lawson L2, .Dragstedt LR II: Vagotomy-pyloroplasty effect on antrum function. Arch Surg 96: 109, 1968. 14. Amdrup E: Surgical treatment of peptic ulcer in depatiment I, Municipal hospital, Copenhagen, present principles and recent results. Acta Chir Stand (suppl) 396: 71, 1969. 121
CHARLES GRAHAM, MD, Nashville,
The standard operation for benign gastric ulcer in the Vanderbilt Medical Center has been partial gastric resection usually limited to the distal half of the stomach, being certain that the antrum was removed along with the gastric ulcer. Gastrointestinal continuity is usually re-established by means of a Billroth I gastroduodenostomy. Since threefourths or more of benign gastric ulcers occur in the prepyloric area or along the lesser curvature of the stomach, it has been possible to perform this operation without difficulty in most patients. The Shoemaker modification of the Billroth I operation permits excision of gastric ulcers on the lesser curvature of the stomach, except for those in the cardia, while preserving sufficient gastric reservoir to prevent anemia and nutritional difficulties. A review of 140 patients with benign gastric ulcer treated by resection revealed a good to excellent result in more than 90 per cent of the patients with a twelve year follow-up period. The mortality was 2.8 per cent. The four deaths occurred in patients who had bled massively and underwent emergency operation [ I]. Recurrent ulcer developed in four patients (2.8 per cent), none of whom had an associated duodenal ulcer. These patients had resection combined with vagotomy. Because of this experience, we have added vagotomy to the operation in recent years. The findings of Ferguson [Z] and Oberhelman and Dragstedt [3] that complete gastric vagotomy reduces the sensitivity of the parietal cells to humeral agents lends support to the concept of vagotomy in the management of benign gastric ulcer. When Farris and Smith [4] reported to the American Surgical Association in 1963 satisfactory results in fifteen patients with benign gastric ulcers managed by vagotomy and pyloroplasty
From the Department Nashville, Tennessee Presented at the gery of the Alimentary
Volume
121,
of Surgery, Vanderbilt University Medical Center, 37203. Eleventh Annual Meeting of the Society for Sur. Tract, Chicago, Illinois, June 20 and 21, 1970.
February 1971
Tennessee
Tennessee Tennessee
with the gastric ulcer left in situ, we began to treat a few patients by this method. Since clinical studies both support and reject the effectiveness of vagotomy and pyloroplasty for the management of gastric ulcer in the absence of associated duodenal ulcer or hypersecretion, we decided to make a clinical study of vagotomy and pyloroplasty in the treatment of benign gastric ulcer in patients seen at the Vanderbilt University Medical Center. Clinical Study
A total of forty-eight patients with benign gastric ulcer and no roentgenologic or operative finding of associated duodenal ulcer have been managed by truncal vagotomy and pyloroplasty performed in a one layer suture closure as described by Weinberg [5]. Gastric ulcers were biopsied by the four quadrant technic and immediate cryostat pathologic examination performed to rule out malignancy (Figure 1.) In no patient has gastric carcinoma been seen. The patients can be grouped into three categories: group I includes twenty-two patients having elective operation for intractable gastric ulcer; group II includes eighteen patients having emergency operation for massive bleeding from a gastric ulcer; and group III is comprised of eight patients who had been on ulcerogenic drugs (aspirin, reserpine, and/or steroids) and who had an emergency operation for massive bleeding. No patient with the so-called “stress ulcer,” ie, acute gastric ulceration developing after trauma or major operation, is included in this study. In group I patients, who underwent elective operation, there were nine men and thirteen women with an age range from thirty to eighty-four years, averaging 55.7 years. Only three of these patients had multiple gastric ulcers. The remainder had single gastric ulcers located in the prepyloric region in two patients, in the antrum in ten, in the body in four, and in the fundus in three. Group II patients, who had an emergency operation for massive bleeding, ranged in age from twenty to 119
Sawyers, Scott, amndGraham
Vagotofny
The operation Figure 1. open biopsy of the gastric layer pyloroplasty.
used in this ulcer, truncal
study consisted of vagotomy, and one
eighty-four years, with an average of fifty-one years. There were fourteen men and four women. Two patients had multiple ulcers whereas the rest had single ulcers located as follows: prepyloric region, two patients ; antrum, five ; the body, four ; and the fundus, five. Group III patients, who had emergency operation for hemorrhage and were on ulcerogenic drugs, ranged in age from fortyfour to ninety-one years. There were five men and three women. Four patients had multiple ulcers located in the body or fundus, and four had single ulcers which were all in the fundic area. Results
Seventeen of the twenty-two patients in group who were treated for intractable gastric ulcer by elective operation, have been judged to have had good to excellent results on follow-up studies for up to 61/s years (average three years). One patient has had only a fair result because of moderate dumping symptoms persistent at follow-up to sixty-four months. Six of the patients with satisfactory results have occasional mild dumping symptoms which are easily controlled by dietary measures. No serious nutritional problems or anemia have occurred. There was no operative mortality in this group. In four patients (18 per cent) in group I recurrent gastric ulcer developed at ten, sixteen, thirtyseven, and fifty months after operation. Only one of these patients was found to have an incomplete vagotomy by the insulin-hypoglycemia (Hollander) test. Reoperation with 40 per cent distal gastrectomy has been necessary in two patients. One refused reoperation despite roentgenographic evidence of recurrent ulcer and a bleeding episode requiring transfusion of 2,000 cc of blood. He was doing well when last seen forty-nine months after operation. The other patient died of massive upper gastrointestinal bleeding sixteen months after operation. At autopsy a recurrent gastric ulcer was I,
120
found in the fundus of the stomach. Anatomic dissection showed no evidence of residual vagal fibers to the stomach and no gastric outlet obstruction. The results in the patients in group II who had vagotomy with pyloroplasty as an emergency operation for massive bleeding from a gastric ulcer were better. Sixteen of eighteen patients (89 per cent) have had good or excellent results with the follow-up period to five years (average three years). There was one operative death in a man who died thirty-two days after operation as a result of clostridial infection of the abdominal wall. At autopsy a superficial gastric ulcer was found near the cardia in the region of his original gastric ulcer. In one patient recurrent gastric ulcer developed in the antrum two years after operation. The ulcer has been demonstrated on upper gastrointestinal x-ray study and manifested by bleeding. The patient is being treated by nonoperative measures, but against surgical advice. One patient in this group had positive results on the Hollander test but is asymptomatic and is considered to have an excellent result. No anemia or nutritional problems have occurred. Two patients have mild dumping symptoms and three patients have mild, intermittent diarrhea but all are satisfactorily controlled by dietary measures. Unsatisfactory results were obtained in the eight patients in group III who underwent operation for massive bleeding and who had been on ulcerogenic drugs, either aspirin, reserpine, and/ or steroids. Only one patient is living with a satisfactory result without reoperation. This patient habitually took aspirin but has now discontinued ingestion of salicylates. Three operative deaths occurred in this group. One patient died from pulmonary embolus and two had rebleeding while in the hospital. One of the two with rebleeding died without reoperation ; the other had gastric resection, which controlled further bleeding, but died of pulmonary complications. Recurrent ulcers have developed in two patients within eighteen months. One has had subtotal resection, and is doing well. The other is under medical treatment with consideration for reoperation. Two patients had late deaths at three an a half and five months after operation from associated cardiovascular disease. The average age in this group was seventy years. Comments
Recent reported clinical results of vagotomypyloroplasty in the treatment of gastric ulcer are shown in Table I. In addition, Woodward has warned of the dangers of pyloroplasty for the treatment of gastric ulcer and reported four patients with recurrent gastric ulcer [11]. He implies The American Journal of Surgery
Vagotomy TABLE
I
Reported Experience with VagotomyPyloroplasty for Gastric Ulcer
Author
Patients
Operative Mortality (per cent)
Dorton [6], 1966 Farris and Smith [7], 1967 Kraft [8], 1968 Stemmer et al [9], 1968 McNeil1 et al [lo], 1969 Present study
30 34 70 34 33 48
7 0 ? 3 3 8
Recurrence (per cent) 7 0 4 38 3 15
that the one layer Weinberg pyloroplasty is not a good drainage procedure and that antral stasis with increased gastrin production led to recurrent gastric ulceration in his patients. Zahn et al [12]. however, did not find evidence of gastric retention on routine gastrointestinal roentgenograms or barium motor meal studies in their postoperative patients. There was a 40 per cent incidence of recurrent gastric ulcer in thirty-eight patients in their series treated by drainage procedures with or without vagotomy, and Zahn et al stated that “it is difficult to explain the recurrence of gastric ulceration after vagotomy-pyloroplasty on the basis of antral stasis or incomplete vagotomy.” Lawson and Dragstedt [13] have shown on the basis of experimental studies in the dog that vagotomy-pyloroplasty results in an accentuated gastric phase of acid secretion. They postulate that although vagotomy-pyloroplasty seems adequate to control the ulcer diathesis in duodenal ulcer patients who have hypersecretion secondary to the cephalic phase of acid secretion, it is doubtful if vagotomy-pyloroplasty will protect against ulcer in patients with gastric ulcer who already have an accentuated gastric phase as the basic defect. Amdrup [1.4] prefers antral resection rather than a drainage procedure for patients with gastric ulcer. He sees no reason for those patients to have a pyloroplasty, much less vagotomy. Elderly patients with gastric ulcer usually have atrophic changes in the gastric mucosa, low response to an augmented histamine test, and evidence of reduced function of their parietal cell mass. In these patients, reduced parietal cell acid secretion with consequent rise in pH in the stomach may stimulate the antrum to a constant state of hyperfunction in an attempt to maintain a pH of 2.5 to 3. Amdrup believes that this theory explains why hyperfunction of the antrum is ulcerogenic and why antrectomy is the preferred operation in the patient with a gastric ulcer. It is important to differentiate between the types of gastric ulcers. The results of treatment of gastric “stress ulcers” and steroid-induced ulcers should not be compared with the solitary Volume 121, February 1971
and Pyloroplasty
for Benign
Gastric
Ulcer
gastric ulcer secondary to antral hyperfunction. If we eliminate the eight patients on ulcerogenic drugs from our study, there would be forty patients managed by vagotomy-pyloroplasty with an ulcer recurrence rate of 12.5 per cent. Because of this high recurrence we believe that vagotomy-pyloroplasty should be reserved for the elderly, poorrisk patient requiring emergency operation for bleeding if he has not been on ulcerogenic drugs as steroids, reserpine, or phenylbutazone. Vagotomypyloroplasty is not as satisfactory as antrectomy and vagotomy for managing the intractable benign gastric ulcer. Summary
A clinical trial of vagotomy and pyloroplasty in the treatment of benign gastric ulcer was performed in forty-eight patients. The incidence of recurrent gastric ulcers was 15 per cent. The results were satisfactory in patients undergoing emergency operation for massive bleeding from a gastric ulcer if the patient had not been on ulcerogenic drugs. However, the operation has not been as satisfactory as antral resection for the management of intractable gastric ulcer. References 1. Adams JE, Sawyers JL, Classen KL, Scott HW Jr: Man-
2.
3.
4.
5. 6.
agement of gastric ulcer. Rocky Mountain Med J 56: 81, 1959. Ferguson DJ: The antral phase of gastric secretion before and after vagotomy: experiments on gastric pouch dogs. Surgery-33: 352, 1953. Oberhelman HA Jr. Dragstedt LR: Effect of vagotomy on gastric secretoj response to histamine.-Proc -Sot Exper Viol Med 67: 336, 1948. Farris JM, Smith GK: Treatment of gastric ulcer (in situ) by vagotomy and pyloroplasty: a clinical study. Ann Surg 158: 461, 1963. Weinberg JA: Pyloroplasty and vagotomy for duodenal ulcer. Curr Probl Surg April, 1964. Dot-ton HE: Vagotomy, pyloroplasty, and suture for bleeding gastric ulcer. Surg Gynec Obstet 122: 1015,
1966. 7. Farris JM, Smith 8.
9.
10.
11.
GK: Quoted in Welch CE, Burke JF: Gastric ulcer reappraisal. Surgery 65: 708, 1969. Kraft RO: In discussion of Stemmer, ‘Zahn, Horn, and Connolly Arch Surg 96: 586, 1968. Stemmer EA, Zahn RL, Horn LW, Connolly JE: Vagotomy and drainage procedure for gastric ulcer. Arch Surg 96: 586, 1968. McNeil1 AD, McAdam WAF, Hutchison JSF: Vagotomy and drainage in the treatment of gastric ulcer. Surg Gynec Obstet 128: 91, 1969. Woodward ER, Eisenberg MM, Dragstedt LR: Recurrence of eastric ulcer after pyloroplasty. Amer J Surgery
113: j, 1967. 12. Zahn RL, Stemmer
EA, Horn LW, Connolly JE: Delayed recurrence of gastric ulcer following vagotomy and drainage procedures. Amer Surg 34: 757, 1968. 13. Lawson L2, .Dragstedt LR II: Vagotomy-pyloroplasty effect on antrum function. Arch Surg 96: 109, 1968. 14. Amdrup E: Surgical treatment of peptic ulcer in depatiment I, Municipal hospital, Copenhagen, present principles and recent results. Acta Chir Stand (suppl) 396: 71, 1969. 121