- Email: [email protected]
Selective Vagotomy of the Parietal Cell Mass Preserving Innervation of the Undrained Antrum
Vol. 59, N o. 4 Print ed in U .S.A.
GASTROENTEROLOGY
Copyright @ 1970 by The Williams & Wilkins Co.
SELECTIVE VAGOTOMY OF THE PARIETAL CELL MASS PRESERVING INNERVATION OF THE UNDRAINED ANTRUM A preliminary report of results in patients with duodenal ulcer E . AMDRUP,
M.D. , PH.D.,
AND HANS-ERIC J ENSEN ,
M .D., PH .D.
Surgical Department I, Kommunehospitalet, Copenhagen, D enmark
Selective vagotomy of the parietal cell mass sparing the innervation of the undrained antrum in treatment of patients with hyperacidity and duodenal ulcer is described. Postoperative gastric emptying is normal. Incidence of dumping is nil. Spontaneous acid secretion and insulin-provoked acid secretion was reduced by about 90%. Penta peptide-provoked acid secretion was reduced by about 60% . Early results are promising in that ulcer pain and acid regurgitation have been completely relieved, but the follow-up period is still too short for further evaluation. Although its incidence can be reduced by restricting operative indications, 1 ' 2 dumping still remains the most common complication of gastric surgery, occurring as frequently after vagotomy and drainage as after partial gastrectomy. 3 Both experimental4-6 and clinical experience 7' 8 indicate that preservation of the integrity of the pylorus effectively prevents dumping. In 1969 Amdrup and Griffith9 reported an operation in animals designed to reduce vagal acid secretion by denervating the parietal cell mass, while preserving normal gastric emptying by sparing the vagal innervation of the antrum and leaving the pylorus intact. In the present paper, results of a similar operation in clinical practice are reported.
this limit is determined with pH-tube after pentapeptide stimulation. Usually a marked change from pH 2 to 6 occurs within 1-cm movement of the pH-tube down the lesser curvature. This is considered a sufficiently accurate definition, and gastrotomy is avoided. If there is doubt, then the stomach is opened along the greater curvature, and the limit determined by staining with Congo red dye. There is clear distinction between red-staining antrum and black-spotted parietal cell mass. Histological examination has proved this distinction to be remarkably accurate. 11 The operation itself is a modification of an earlier described procedure entailing selective vagotomy. 12 The technique is illustrated in figures 1 to 4. A finger is inserted through the avascular part of the lesser omentum and passed behind the .o mentum to the lesser curvature. The serosa is cut in front of the lesser curvature, and the lesser omentum is dissected free from the stomach against the finger, and therefore very close to the lesser curvature. Thus, damage to the anterior and posterior gastric nerves is avoided. A dissection begun at the determined antral margin may result in bleeding during the operative manipulations as a whole and there is risk that as a result distal dissection may have to be made involving the proximal antrum. To guard against the possibility of denervating the proximal antrum, the dissection is begun about 2 em proximal to the determined antral limit. The lesser omentum is dissected proximally
Methods Operative Technique Animal experiments 10 have shown that it is important to define the antral limit as accurately as possible. If the proximal antrum is denervated stasis results. When possible Received January 26, 1970. Accepted April1, 1970. Address requests for reprints to: Dr. E. Amdrup, Surgical Department I, Kommunehospitalet, Copenhagen, Denmark. This work was supported in part by a grant from F . L. Smidth.
522
Octob er 1970
SELECTIVE VAGOTOMY OF PARIETAL CELL MASS
523
,; i
b. :~~
FrG. 1
.-
.
·"
./
FIG . 2
from the lesser curvature keeping as close as possible to the stomach. This is facilitated by mild traction on the curvature through a holding stitch. A ring dissection of the esophagus is then effected_ Nerve twigs are identified and cut on every aspect. Finally the omentum is dissected distally down to the marked antral limit_ The technique is slightly more difficult than selective gastric vagotomy in which
traction can be exerted on both the lesser omentum and stomach. Series Since January 1969, 2~ patients have undergone this operation. Patients were selected who evidenced marked acid hypersecretion on pentapeptide activation, but who had no signs of pyloric stenosis resulting from their duodenal ulcers. Routine preoperative investiga-
AMDRUP AND JENSEN
524
1. 1
FIG. 3.
tion of all patients included barium meal, gastric motility studies, ' 3 and the pentapeptide test. Some underwent, in addition, the insulin test. These investigations were repeated 6 to 8 weeks postoperatively.
Results No postoperative complications have
Vol . 59, No. 4
arisen. Specifically, there have been no signs of gastric stasis. Gastrotomy pa. tients had constant gastric suction for 4 days. Gastric tubes were removed from the other patients, and food was given by mouth on the 2nd day. Ulcer pain and acid regurgitation have been totally re. lieved to date, but clearly the postopera. tive course is too short for valid conclusions as yet. When dumping occurs following operations on the stomach it usually does so within the first months. The patients in this series resumed their normal diets within weeks, and evidenced no signs of dumping, even after liquid carbohydrate meals. None of the patients have had symptoms of gastric retention. Bowel habits remain or have returned to normal since the operation. Diarrhea has not occurred . At this time, objective evaluation of the patients condition is of most interest. The gastric emptying time and the small intestinal transit time of a physiological contrast medium has been evaluated in 14
FIG. 4
SELECTIVE VAGOTOMY OF PARIETAL CELL MASS
October !970
525
tric stasis is to be avoided. 14 · "' Ferguson 16 et a l . undertook segmental resection of the parietal cell mass preserving the innervated antrum. No drainage procedure was employed and gastric emptying- was reported normal. The operation described in this paper is an extension of Ferguson's principle, differing in that it is a lesser procedure, and perhaps also in that parietal cell acid secretion is further reduced. Burg-e 17 sug-gested that patients with nonstenosingduodenal ulcers should be treated by selective vagotomy without pyloroplasty, but with preservation of the pyloric branch of the hepatic nerve. However, as early as 1947, Franksson IH tried such a procedure, and 4 of 7 patients came to operation again with recurrent ulcer.'!' Animal experiments have shown that selective gastric vagotomy without drainage predisposes to stasis."' A vag-otomy denervating the proximal stomach and again sparing the antral innervation has been tried by Holle and Hare" and Hedenstedt.21 These authors included pyloroplasty in the procedure. Their intent m
patients. Repeated survey exposures and cinematography demonstrated no change in antral motility and gastric emptying. The fasting secretion (15 min aspirate immediately after intubation) was reduced in volume by a mean of 39% (sn ± 27) (from 130 ± 72 to 79 ± 39 ml). Basal secretion (aspirate over 1 hr) showed a reduction of acid content of 87% (table 1). Reduction in pentapeptide activated acid secretion was 62 %. Postoperative insulin test was performed in 17 patients: 11 were negative, 2 positive in the 1st hr, and 4 positive in the 2nd hr. The results are shown in table 2, expressed in peak insulin and maximal insulin acid output and total acid secretion in a 2-hr period. Twelve of the patients underwent insulin test both pre- and postoperatively. The results showed an average peak insulin acid output reduction of 91% and a similar reduction in aspirate taken 2 hr after insulin injection (table 3). Discussion There are several reports that the denervated antrum must be drained if gas-
1. Pre- and postoperative basal secretion (1-hr collection) and PPAO (peak p entapeptidc ncid output) in 17 patients with vagotomy of the parietal cell mass without draina~-:e procedure"
TABLE
Acid
Volum e
ml!ci/ilr
Basa l secretion
Preoperative Postoperative Reduction ('/(,) Pre-operative Postoperative Reduction ('/(,)
PPAO
5.4 0.7 87 43.6 16 .8 62
± ± ± ± ± ±
ml
4 .8 1.6 15 15.8 10 .0 19
145 90 :>8 477 2G7 44
±
Gl
± 44 ± 21 ± 127 ± RO ± lfl
" Values given are mean plus or minus sta ndard deviation . TABLE
2. Postoperative insulin test (0.2 U per kg) in 17 patients with vagotomy of the pnrictnl cdl mass without drainage procedure" Patient
I
2
:1
PIAO MIAO
5.2 4.5
4.4 3.6
1.0 0.5
2.4 2.3
Total per 2-hr secretion
5.1
3.9
0.6
2.4
No.
4
10
II
12
t:l
H
\f)
Hi
17
7
8
9
2.4 1.8
0 0 0 0
0 0
2.2 1.5
0 2.6 2.6 0.6 0 1.8 1.3 0.6
1.6 9.8 1.8 1.5 7.1 1.5
1.4 1.3
3. 1
0 0
0
1.7
0 1.8 1.3 0.6
2.5 8.1 1.5
1.8
5
6
"PIAO (peak msuhn actd output) and MIAO (maxtmal msuhn actd output) are expressed as milhequlvalents per hour, and total2·hr secretion as milliequivalents.
526
Vol. 59, No. 4
AMDRUP AND JENSEN TABLE
3. Pre- and postoperative insulin test results in 12 patients with vagotomy of the parietal cell
mass without drainage procedure' Acid
Volume
ml
mEq/hr
PIAO
MIAO
Total acid secreted in 2 hr
Preoperative Postoperative Reduction Preoperative Postoperative Reduction Preoperative Postoperative Reduction
29.0 2.5 91 27. 5 2.0 93 38.3 2.2 94
± 11.3 ± 2 .7 ± 8 ± 10. 3 ± 2.0 ± 7.0 ± 15.0 ± 2.3 ± 5
329 ±
± 65 ±
114
88 79 20
479 ± 158 155 ± 94 68 ± 15
' Values are given as mean plus or minus standard deviation .
preserving antral innervation was preservation of the probable antral mechanism inhibiting acid secretion. Radiological examination of our patients demonstrates that the antral nerves are essential in the normal process of gastric emptying and that by preserving them antral motility is unimpaired. Total spontaneous secretion is not much reduced, but the acid content is markedly reduced. The fact that fasting secretions are not increased postoperatively, argues perhaps more strongly than X-ray studies that gastric stasis does not occur. The marked reduction in insulin-activated acid secretion apparently demonstrates that the operative technique described is effective in denervating the parietal cell mass, and further that insulin-activated vagal release of gastrin from the empty antrum is, at most, modest. Sham-feeding experiments have not been undertaken. Although it may be desirable to reduce pentapeptide-activated acid secretion further, it is not clear how this can be effected or whether it is necessary, nor can any valid assessment of this treatment of duodenal ulcer be made. Although total disappearance of ulcer pain and acid regurgitation is promising, clearly, longer follow-up is necessary. It is, however, apparent that selective vagotomy of the parietal cell mass can effect a very significant reduction in vagally mediated acid secretion of the stomach. Further-
more, normal gastric emptying is ap. parently unaffected after the described operation. Drainage is unnecessary and dumping does not occur. REFERENCES 1. Amdrup E: Variation in food tolerance after partial gastrectomy. Acta Chir Scand 120:410-421, 1961 2. Sander GB: Discussion to Rutledge, RH: Jejunal segments for the postgastrectomy syndromes. Ann Surg 169:825-826, 1969 3. Amdrup E, Andreassen JC , Bach-Nielsen P: Results of partial gastrectomy for peptic ulcer. Acta Chir Scand Suppl 396:18-28, 1969. 4. Friesen SR, Rieger E: A study of the role of the pylorus in the prevention of the dumping syndrome. Ann Surg 151:517-529, 1960 5. Killen DA, Symbas PN: Effect of preservation of the pyloric sphincter during antrectomy on postoperative gastric emptying. Amer J Surg 104: 836-842, 1962 6. Flynn PJ, Longmire WP: Subtotal gastrectomy with sphincter preservation. Surg Forum 10:185188, 1960 7. Maki T, Shirotore T, Hatufuku T, et al: Pylorus preserving gastrectomy as an improved operation for gastric ulcer. Surgery 61:838-845, 1967 8. Amdrup E, Jensen HE, Nielsen J: Treatment of benign gastric ulcer by segmental gastric resection with and without pyloroplasty. Surgery (in press) 9. Amdrup BM, Griffith CA: Selective vagotomy of the parietal cell mass. Part 1: with preservation of the inn ervated antrum and pylorus. Ann Surg 170:207-214, 1969 10. Griffith, CA, Harkins HN: Partial gastric vagotomy: An experimental study. Gastroenterology 32:96-102, 1957
October 1970
SELECTIVE VAGOTOMY OF PARIETAL CELL MASS
11. Moe RE, Nyhus LN, Harkins HN: The use of dye for differentiating the gastric antrum from the gastric corpus. Bull Soc Int Chir 22:424-434, 1963 12. Amdrup E, Clemmesen TH, Andreassen JC: Selective gastric vagotomy. Technic and primary results . Amer J Dig Dis 12:351-355. 13. Madsen P, Rasmussen T: Postgastrectomy roentgenography with a physiologic contrast medium . Acta Radio! (Stockholm) 2:153-160, 1964 14. Dragstedt LR, Camp EH, Fritz JM: Recurrence of gastric ulcer after complete vagotomy. Ann Surg 130:843-854, 1949 15. Shiina E, Griffith CA: Selective and total vagotomy without drainage. Ann Surg 169:326-333, 1969 16. Ferguson DJ, Billings H, Swensen D, et al: Seg-
17.
18. 19. 20.
21.
527
mental gastrectomy with innervated antrum for duodenal ulcer. Surgery 47:548-556, 1960 Burge H: The anatomy of the abdominal vagus with special reference to bilateral selective nerve section, The Physiology of Gastric Secre. tion. Edited by LS Semb, J Myren. Universitetsforlaget, Oslo, 1968, p 27-35 Franksson C: Selective abdominal vagotomy. Acta Chir Scand 96:409-412, 1948 Franksson C: Nervus vagus anatomi och vagot. omi. Nord Med 78:1114- 1116, 1967 Holle F, Hart W: Neue Wege der chirurgie des gastro-duodenal ulcus. Med Klin 62:441-450, 1967 Hedenstedt S: Selectiv proximal vagotomi og pyloroplastik. Svensk kirurgisk forening, m¢de den 28.11.68. Ref. Nord Med 82:1226-1227,1969
GASTROENTEROLOGY
Copyright @ 1970 by The Williams & Wilkins Co.
SELECTIVE VAGOTOMY OF THE PARIETAL CELL MASS PRESERVING INNERVATION OF THE UNDRAINED ANTRUM A preliminary report of results in patients with duodenal ulcer E . AMDRUP,
M.D. , PH.D.,
AND HANS-ERIC J ENSEN ,
M .D., PH .D.
Surgical Department I, Kommunehospitalet, Copenhagen, D enmark
Selective vagotomy of the parietal cell mass sparing the innervation of the undrained antrum in treatment of patients with hyperacidity and duodenal ulcer is described. Postoperative gastric emptying is normal. Incidence of dumping is nil. Spontaneous acid secretion and insulin-provoked acid secretion was reduced by about 90%. Penta peptide-provoked acid secretion was reduced by about 60% . Early results are promising in that ulcer pain and acid regurgitation have been completely relieved, but the follow-up period is still too short for further evaluation. Although its incidence can be reduced by restricting operative indications, 1 ' 2 dumping still remains the most common complication of gastric surgery, occurring as frequently after vagotomy and drainage as after partial gastrectomy. 3 Both experimental4-6 and clinical experience 7' 8 indicate that preservation of the integrity of the pylorus effectively prevents dumping. In 1969 Amdrup and Griffith9 reported an operation in animals designed to reduce vagal acid secretion by denervating the parietal cell mass, while preserving normal gastric emptying by sparing the vagal innervation of the antrum and leaving the pylorus intact. In the present paper, results of a similar operation in clinical practice are reported.
this limit is determined with pH-tube after pentapeptide stimulation. Usually a marked change from pH 2 to 6 occurs within 1-cm movement of the pH-tube down the lesser curvature. This is considered a sufficiently accurate definition, and gastrotomy is avoided. If there is doubt, then the stomach is opened along the greater curvature, and the limit determined by staining with Congo red dye. There is clear distinction between red-staining antrum and black-spotted parietal cell mass. Histological examination has proved this distinction to be remarkably accurate. 11 The operation itself is a modification of an earlier described procedure entailing selective vagotomy. 12 The technique is illustrated in figures 1 to 4. A finger is inserted through the avascular part of the lesser omentum and passed behind the .o mentum to the lesser curvature. The serosa is cut in front of the lesser curvature, and the lesser omentum is dissected free from the stomach against the finger, and therefore very close to the lesser curvature. Thus, damage to the anterior and posterior gastric nerves is avoided. A dissection begun at the determined antral margin may result in bleeding during the operative manipulations as a whole and there is risk that as a result distal dissection may have to be made involving the proximal antrum. To guard against the possibility of denervating the proximal antrum, the dissection is begun about 2 em proximal to the determined antral limit. The lesser omentum is dissected proximally
Methods Operative Technique Animal experiments 10 have shown that it is important to define the antral limit as accurately as possible. If the proximal antrum is denervated stasis results. When possible Received January 26, 1970. Accepted April1, 1970. Address requests for reprints to: Dr. E. Amdrup, Surgical Department I, Kommunehospitalet, Copenhagen, Denmark. This work was supported in part by a grant from F . L. Smidth.
522
Octob er 1970
SELECTIVE VAGOTOMY OF PARIETAL CELL MASS
523
,; i
b. :~~
FrG. 1
.-
.
·"
./
FIG . 2
from the lesser curvature keeping as close as possible to the stomach. This is facilitated by mild traction on the curvature through a holding stitch. A ring dissection of the esophagus is then effected_ Nerve twigs are identified and cut on every aspect. Finally the omentum is dissected distally down to the marked antral limit_ The technique is slightly more difficult than selective gastric vagotomy in which
traction can be exerted on both the lesser omentum and stomach. Series Since January 1969, 2~ patients have undergone this operation. Patients were selected who evidenced marked acid hypersecretion on pentapeptide activation, but who had no signs of pyloric stenosis resulting from their duodenal ulcers. Routine preoperative investiga-
AMDRUP AND JENSEN
524
1. 1
FIG. 3.
tion of all patients included barium meal, gastric motility studies, ' 3 and the pentapeptide test. Some underwent, in addition, the insulin test. These investigations were repeated 6 to 8 weeks postoperatively.
Results No postoperative complications have
Vol . 59, No. 4
arisen. Specifically, there have been no signs of gastric stasis. Gastrotomy pa. tients had constant gastric suction for 4 days. Gastric tubes were removed from the other patients, and food was given by mouth on the 2nd day. Ulcer pain and acid regurgitation have been totally re. lieved to date, but clearly the postopera. tive course is too short for valid conclusions as yet. When dumping occurs following operations on the stomach it usually does so within the first months. The patients in this series resumed their normal diets within weeks, and evidenced no signs of dumping, even after liquid carbohydrate meals. None of the patients have had symptoms of gastric retention. Bowel habits remain or have returned to normal since the operation. Diarrhea has not occurred . At this time, objective evaluation of the patients condition is of most interest. The gastric emptying time and the small intestinal transit time of a physiological contrast medium has been evaluated in 14
FIG. 4
SELECTIVE VAGOTOMY OF PARIETAL CELL MASS
October !970
525
tric stasis is to be avoided. 14 · "' Ferguson 16 et a l . undertook segmental resection of the parietal cell mass preserving the innervated antrum. No drainage procedure was employed and gastric emptying- was reported normal. The operation described in this paper is an extension of Ferguson's principle, differing in that it is a lesser procedure, and perhaps also in that parietal cell acid secretion is further reduced. Burg-e 17 sug-gested that patients with nonstenosingduodenal ulcers should be treated by selective vagotomy without pyloroplasty, but with preservation of the pyloric branch of the hepatic nerve. However, as early as 1947, Franksson IH tried such a procedure, and 4 of 7 patients came to operation again with recurrent ulcer.'!' Animal experiments have shown that selective gastric vagotomy without drainage predisposes to stasis."' A vag-otomy denervating the proximal stomach and again sparing the antral innervation has been tried by Holle and Hare" and Hedenstedt.21 These authors included pyloroplasty in the procedure. Their intent m
patients. Repeated survey exposures and cinematography demonstrated no change in antral motility and gastric emptying. The fasting secretion (15 min aspirate immediately after intubation) was reduced in volume by a mean of 39% (sn ± 27) (from 130 ± 72 to 79 ± 39 ml). Basal secretion (aspirate over 1 hr) showed a reduction of acid content of 87% (table 1). Reduction in pentapeptide activated acid secretion was 62 %. Postoperative insulin test was performed in 17 patients: 11 were negative, 2 positive in the 1st hr, and 4 positive in the 2nd hr. The results are shown in table 2, expressed in peak insulin and maximal insulin acid output and total acid secretion in a 2-hr period. Twelve of the patients underwent insulin test both pre- and postoperatively. The results showed an average peak insulin acid output reduction of 91% and a similar reduction in aspirate taken 2 hr after insulin injection (table 3). Discussion There are several reports that the denervated antrum must be drained if gas-
1. Pre- and postoperative basal secretion (1-hr collection) and PPAO (peak p entapeptidc ncid output) in 17 patients with vagotomy of the parietal cell mass without draina~-:e procedure"
TABLE
Acid
Volum e
ml!ci/ilr
Basa l secretion
Preoperative Postoperative Reduction ('/(,) Pre-operative Postoperative Reduction ('/(,)
PPAO
5.4 0.7 87 43.6 16 .8 62
± ± ± ± ± ±
ml
4 .8 1.6 15 15.8 10 .0 19
145 90 :>8 477 2G7 44
±
Gl
± 44 ± 21 ± 127 ± RO ± lfl
" Values given are mean plus or minus sta ndard deviation . TABLE
2. Postoperative insulin test (0.2 U per kg) in 17 patients with vagotomy of the pnrictnl cdl mass without drainage procedure" Patient
I
2
:1
PIAO MIAO
5.2 4.5
4.4 3.6
1.0 0.5
2.4 2.3
Total per 2-hr secretion
5.1
3.9
0.6
2.4
No.
4
10
II
12
t:l
H
\f)
Hi
17
7
8
9
2.4 1.8
0 0 0 0
0 0
2.2 1.5
0 2.6 2.6 0.6 0 1.8 1.3 0.6
1.6 9.8 1.8 1.5 7.1 1.5
1.4 1.3
3. 1
0 0
0
1.7
0 1.8 1.3 0.6
2.5 8.1 1.5
1.8
5
6
"PIAO (peak msuhn actd output) and MIAO (maxtmal msuhn actd output) are expressed as milhequlvalents per hour, and total2·hr secretion as milliequivalents.
526
Vol. 59, No. 4
AMDRUP AND JENSEN TABLE
3. Pre- and postoperative insulin test results in 12 patients with vagotomy of the parietal cell
mass without drainage procedure' Acid
Volume
ml
mEq/hr
PIAO
MIAO
Total acid secreted in 2 hr
Preoperative Postoperative Reduction Preoperative Postoperative Reduction Preoperative Postoperative Reduction
29.0 2.5 91 27. 5 2.0 93 38.3 2.2 94
± 11.3 ± 2 .7 ± 8 ± 10. 3 ± 2.0 ± 7.0 ± 15.0 ± 2.3 ± 5
329 ±
± 65 ±
114
88 79 20
479 ± 158 155 ± 94 68 ± 15
' Values are given as mean plus or minus standard deviation .
preserving antral innervation was preservation of the probable antral mechanism inhibiting acid secretion. Radiological examination of our patients demonstrates that the antral nerves are essential in the normal process of gastric emptying and that by preserving them antral motility is unimpaired. Total spontaneous secretion is not much reduced, but the acid content is markedly reduced. The fact that fasting secretions are not increased postoperatively, argues perhaps more strongly than X-ray studies that gastric stasis does not occur. The marked reduction in insulin-activated acid secretion apparently demonstrates that the operative technique described is effective in denervating the parietal cell mass, and further that insulin-activated vagal release of gastrin from the empty antrum is, at most, modest. Sham-feeding experiments have not been undertaken. Although it may be desirable to reduce pentapeptide-activated acid secretion further, it is not clear how this can be effected or whether it is necessary, nor can any valid assessment of this treatment of duodenal ulcer be made. Although total disappearance of ulcer pain and acid regurgitation is promising, clearly, longer follow-up is necessary. It is, however, apparent that selective vagotomy of the parietal cell mass can effect a very significant reduction in vagally mediated acid secretion of the stomach. Further-
more, normal gastric emptying is ap. parently unaffected after the described operation. Drainage is unnecessary and dumping does not occur. REFERENCES 1. Amdrup E: Variation in food tolerance after partial gastrectomy. Acta Chir Scand 120:410-421, 1961 2. Sander GB: Discussion to Rutledge, RH: Jejunal segments for the postgastrectomy syndromes. Ann Surg 169:825-826, 1969 3. Amdrup E, Andreassen JC , Bach-Nielsen P: Results of partial gastrectomy for peptic ulcer. Acta Chir Scand Suppl 396:18-28, 1969. 4. Friesen SR, Rieger E: A study of the role of the pylorus in the prevention of the dumping syndrome. Ann Surg 151:517-529, 1960 5. Killen DA, Symbas PN: Effect of preservation of the pyloric sphincter during antrectomy on postoperative gastric emptying. Amer J Surg 104: 836-842, 1962 6. Flynn PJ, Longmire WP: Subtotal gastrectomy with sphincter preservation. Surg Forum 10:185188, 1960 7. Maki T, Shirotore T, Hatufuku T, et al: Pylorus preserving gastrectomy as an improved operation for gastric ulcer. Surgery 61:838-845, 1967 8. Amdrup E, Jensen HE, Nielsen J: Treatment of benign gastric ulcer by segmental gastric resection with and without pyloroplasty. Surgery (in press) 9. Amdrup BM, Griffith CA: Selective vagotomy of the parietal cell mass. Part 1: with preservation of the inn ervated antrum and pylorus. Ann Surg 170:207-214, 1969 10. Griffith, CA, Harkins HN: Partial gastric vagotomy: An experimental study. Gastroenterology 32:96-102, 1957
October 1970
SELECTIVE VAGOTOMY OF PARIETAL CELL MASS
11. Moe RE, Nyhus LN, Harkins HN: The use of dye for differentiating the gastric antrum from the gastric corpus. Bull Soc Int Chir 22:424-434, 1963 12. Amdrup E, Clemmesen TH, Andreassen JC: Selective gastric vagotomy. Technic and primary results . Amer J Dig Dis 12:351-355. 13. Madsen P, Rasmussen T: Postgastrectomy roentgenography with a physiologic contrast medium . Acta Radio! (Stockholm) 2:153-160, 1964 14. Dragstedt LR, Camp EH, Fritz JM: Recurrence of gastric ulcer after complete vagotomy. Ann Surg 130:843-854, 1949 15. Shiina E, Griffith CA: Selective and total vagotomy without drainage. Ann Surg 169:326-333, 1969 16. Ferguson DJ, Billings H, Swensen D, et al: Seg-
17.
18. 19. 20.
21.
527
mental gastrectomy with innervated antrum for duodenal ulcer. Surgery 47:548-556, 1960 Burge H: The anatomy of the abdominal vagus with special reference to bilateral selective nerve section, The Physiology of Gastric Secre. tion. Edited by LS Semb, J Myren. Universitetsforlaget, Oslo, 1968, p 27-35 Franksson C: Selective abdominal vagotomy. Acta Chir Scand 96:409-412, 1948 Franksson C: Nervus vagus anatomi och vagot. omi. Nord Med 78:1114- 1116, 1967 Holle F, Hart W: Neue Wege der chirurgie des gastro-duodenal ulcus. Med Klin 62:441-450, 1967 Hedenstedt S: Selectiv proximal vagotomi og pyloroplastik. Svensk kirurgisk forening, m¢de den 28.11.68. Ref. Nord Med 82:1226-1227,1969