Current operations for duodenal ulcer

T A B L E OF C O N T E N T S

HISTORICAL NOTF-S .

6

OPERATIONS CURRENTLY EMPLOYED FOR DUODENAL ULCER

8

Gastric Resection Alone

.

Vagotomy with D r a i n a g e

.

.

.

Vagotomy and Conservative Resection

8 10

.

.

LESS FREQUENTLY EMPLOYED OPERATIONS

16 23

Supra-Antral Segmental Resection

24

Aniro-Dista! D u o d e n o s t o m y

25

Proximal Duodenectomy-Distat Pylorectomy

26

Simple G a s t r o e n t e r o s t o m y .

26

NEWER SU~RGICAL PROCEDURES

27

Reversal of the D u o d e n u m .

27

Mucosal A n t r e c i o m y with V a g o t o m y .

31

Suprapyloric Antrectomy with Vagotomy

34

Selective Vagotomy without Drainage

38

H i g h l y Selective Vagotom_.y without Drainage

41

TESTS TO DL~FERMINE THE COMPLETENF'SS OF VAGOTO~,IY

47

DISCUSSION

50

SUMMARY

53

3

i.,; engaged in _the pri'~aie practice of S u r g e r y in Nashville, Tennessee, a n d is a m e m b e r of the E d w a r d s - E v e Clinic Association. H e is Associate Professor of Clinical S u r g e r y at the V a n d e r b i l t U n i v e r s i t y M e d i c a l Center, 1)oc{or Herr, ington received his B.A. degree from Vanderbilt. a t t e n d e d the Medical College of Georgia a n d was graduate(] from the Vanderbilt Univers i t y School of Medicine. H e served an interrLship in S u r g e r y u n d e r the late I)r. B,~rney Brooks at V a n d e r b i l t a n d completed a surgical residency u n d e r the late I.eonard E d w a r d s at St. T h o m a s Hospital. After a tour of d u t y with the Armed Forces in J a p a n a n d K o r e a , he became associated with Doctor E d w a r d s as a m e m b e r of the E d w a r d s - E v e Clinic. D o c t o r H e r r i n g t o n ' s chief interest is in s u r g e r y of the g a s t r o i n t e s t i n a l tract, a field in which he has m a d e m a n y contributions. He is a m e m b e r of m a n y of the o u t s t a n d i n g surgical organizations.

A T P R E S E N T , considerable difference of opinion exists as to the choice of operation for control of the complications of duodenal ulcer. T h e r e are those who insist that the time-honored operation of adequate distal gastrectomy continues to,give superior results. O t h e r s~jrgeons prefer a more c o n servative dist:~l resection combined with vagotomy, whereas still others condemn any degree of resection, except in selected circumstances, and stress vagotomy in combination with a drainage procedure. A large number of surgeons seek to avoid prejudice and emphasize the importance of selecting from among the procedures mentioned the one t h a t best meets the needs of the patient. Over the years, each of the above operations has, in general, produced over-all satisfactory results, but any definitive operation performed on the stomach that sacrifices gastric tissue or alters the pyloric sphincter will, in a certain percentage of cases, result in undesirable Iongterm sequelae. Thus, the search continues for the ideal operation for ,']uodenal ulcer. i n recent years, some surgical investigators have applied various technical modifications to the currently established operations for duodenal ulcer with the hope not only of controlling the u n d e r l y i n g ulcer pathophysiology but also of eliminating undesirable long-term sequelae. Some of these modifications still ..-ire considered to be in the infant stage and are by no means ready for widespread clinical application. T h e y include modifying the type o~ vagal denervation, eliminating altogether gastric drainage or resection in selected cases, adding new technics to a m rectomy, limiting the e:~tent of distal resection, preservation of the pyloric sphincter, a n d even physiologically reversing the entire duodenum. It is the purpose of this m o n o g r a p h to assemble in concise form the current experiences and results being obtained with the generally accepted surgical procedures for duodenal ulcer and to describe the recei~! modalities that are being carefully investigated by surgeons in certain surgical centers. 5

Tl'ie m a t e r i a l for the m o n o g r a p h was made possible by a host of surgical friends and colleagues fl~roughout the world, to whom I / a m most urateful and appreciative.

HISTORICAL NOTES Before and during most of the e i g h t e e n t h century, su:rgica~ procedures on the stomach were limited to the removal of foreign bodies (usually swallowed knives) and to the s u t u r i n g of wounds. D u r i n g the middle of the n i n e t e e n t h century, gastrostomy was a t t e m p t e d on a n u m b e r of occasions, but always with a fatal outcome. It was not until 1875 that S y d n e y Jones of St. T h o m a s ' Hospital in London performed a successful gastrostomy on a patient with a m a l i g n a n t esophageal obstruction. 20s According to Temkin,237 the first proposal to extirpate a m a l i g n a n t growth from the h u m a n stomach was made by Michaelis (1780), then professor of surgery and a n a t o m y at the University of Marburg. Removal of the pylorus in both the dog and the rabbit was carried out by Michaelis and his celebrated pupil, T h e o d o r e M e r r e m , in 1810.I;,~ Neither, however, subsequently applied the operation to man. Surgicall history reveals t h a t a P h i l a d e l p h i a physician m a d e the earliest a t t e m p t t!o c a r r y out pylorectomy in the experimental animal, being inspired in his experiments by observing a medical colleague with a carcinoma of the distal portion of the stomach. F u r t h e r historical research shows t h a t this physician was indeed Michaelis himself, who at the time was serving as an a r m y physician with the Hessian troops in t h e United States. A n e x p e r i m e n t a l s t u d y of pylorectomy was published in 1876 by Carl G u s s e n b a u e r and Alexander yon Winiwarter,SS both assistants to Professor T h e o d o r Billroth of Vienna. As a result of this work, the awareness of the feasibility of resecting the pylorus for m a l i g n a n t obstructior~ spread rather widely throughout the surgical world. In 1879, the illustrious French surgeon J u l e s Pdan192 was the first to clinically a t t e m p t a pyloric resection for carcinoma but vdthout success. P d a n had not carried out experimental studies prior to e m b a r k i n g on this hazardous endeavor. In 1880, the Polish surgeon Ludwig von l:tydygier,212 who possessed both experimental and clinical backgrounds, was the second to a t t e m p t a distal gastric resection for carcinoma, also followed by a fatal outcome. Von R y d y g i e r later performed the first distal resection for a benign gastric ulcer and also is credited with c a r r y i n g out the first gastroenterostomy for qtuodena] ulcer. T h e third a t t e m p t , which resulted in the first successful pyloric excision, was carried out in J a n u a r y , 1881, by Professor T h e o d o r Billroth19 on a patient with an obstructing pyloric carcinoma. In his initial operation, Billroth anastomosed the lesser curve of the gastric pouch to the open end of the duoden u m a f t e r closure of the greater curve. In subsequent operations, he utilized the greater curve of the s t o m a c h for the anastomosis. Als9 in 1881, WSlfler,259 one of Billroth's assistants, performed the first antecolic gastroj e j u n o s t o m y for carcinoma. I n 1885, Billroth20 p e r f o r m e d an antecolic gastrojejunostomy, along with extirpation of a pyloric carcinoma and closed both the transected ends of the stomach and duodenum. Thus, the Billroth I I procedure was born. D u r i n g this era a n d even in the first p a r t of ~he twentieth century, most distal gastric resections and gastroenterostomies were performed for car6

cinoma and benign gastric ulcer. Several modifications of the Billroth I and Billroth 1I methods were devised and even t.oday there is difference of opinion and controversy as to the exact originators. As late as 1895, gastric and d~mdenal ulcer were not recognized as different entities; indeed, duodenal ulcer disease was considered to be rare. Gussenbauer and yon WiniwarterSS hml stated in 1876 that perhaps pylorectomy m i g h t be applicable to benign stenotic lesions of the distal stomach, but it was not until 1905 that R y d y gier defended pylorectomy for dlmdenal ulcer before the 1st I n t e r n a t i o n a l College in Brussels. Jedlicka also advocated resection for duodenal ulcer before the G e r m a n Surgical Society in 1906. As the true significance a n d incidence of duodenal ulcer became better appreciated, keen and bitter controversy developed among the advocates of resection on the one hand and those favoring simple gastroenterostomy on the other. Such outstanding surgeons as Doyen, Rydygier, Kronlein, Kocher and B r a u n preferred gastroenterostomy, whereas von H a b e r e r , von H a c k e r and F i n s t e r e r advocat,ed resection. T h e latter three surgeons were a m o n g the first to recognize the fallacy of gastroenterostomy as well as the pitfalls of the von Eiselsberg exclusion operation. Unquestionably, yon H a b e r e r and F i n s t e r e r did more than a n y o n e in their era to broaden the scope of surgery for duodenal ulcer and to increase the extent of resection of both gastric and duodenal ulcer as well as gastric carcinoma.90, 232 Gastric resection as definitive t r e a t m e n t for the complications of duodenaI ulcer was slow to gain favor in America due notably to the international influence of Berkeley M o y n i h a n of Leeds and William J. M a y o of Rochester, both staunch advocates of simple gastroenterostomy. It was through the persistent efforts of Strauss, Berg and Lewisohn in America that gastric resection was shown to provide results superior to those obtained with simple gastroenterostomy. Shortly after the end of World W a r I, the unsatisfaciory results with gastroenterostomy became a p p a r e n t , but it was not until the 1930s that gastric resection for the t r e a t m e n t of duodenal ulcer became widely accepted in the United States.156-15s, 167-I70, 180-183, 235 T h e importance of vagal nerve stimulation in inducing a profound gastric secretory, response was first noted by Sir B e n j a m i n Brodie21 in 1814. Later, Claude B e r n a r d l ; (1858) observed a depression of gastric secretions and arrest of stomach contractions following vagal division in the experimental animal. Other physiologists, such as Pavlov191 and Schiff,217 likewise observed that the gastric secretory response dropped following vagotomy. In 1914, E x n e r and Schwartzmann4S were perhaps the first to divide the vagus nerves in the h u m a n via the abdominal route. Most of these early opera: tions were performed for tabetic crisis or functional disease of the gastrdintestinal tract. L a t e r investigators added gastroenterostomy to the vagal section to overcome the atonic effects of vagotomy on the stomach. In 1922, Latarjeti 52 added p y l d r e c t o m y t o vagotomy for cases of benin1 gastric outlet obstruction. I n 1925, Schiassi21d mentioned the addition of gastroenterostomy to denervation in patients with pyloric stenosis. Klein143 (1929) and Winkelstein and Berg (1938--1942) employed a partial vagotomy and resection for patients with duodenal ulcer.257, 25s The works of these observers a p p a r e n t l y went largely unrecognized, and follow-up data, =mfortunately, were not published. As a result, vagotomy fell into general disuse for almost two decades. Little m e n t i o n w,~s given the subject until 1943, when D r a g s t e d t and Owens3S published their classic 7

p a p e r on the beneficial effects of vagotomy on the healing of duodenal ulcer. This publication and the subsequent reports of others served to produce a surgical a w a k e n i n g as regards the t r e a t m e n t of duodenal ulcer. As a result of the u n t i r i n g endeavors of Lester Dragstedt, Sr., vagotomy has now become an integral p a r t oi' most operations performed for duodenal ulcer.

OPERATIONS CURRENTLY EMPLOYED FOR DUODENAL ULCER No one operative procedure has achieved universal acceptance for treatm e n t of the complications of duodenal ulcer. T h e operations presently most widely e m p l o y e d by most surgeons are adequate subtotal gastrectomy of the Billroth I I type without vagotomy, vagotomy, either truncal or selective, combined with a d e q u a t e gastric drainage, and truncal vagotomy combined with a conservative distal resection. GASTRIC RESECTION ALONE Gastric resection of the Billroth I I type without vagotomy unquestionably was the most frequently e m p l o y e d operative procedure for control of ulcer complications during the 1930s and 1940s. However, during the past two decades, as a result of the steadily growing e n t h u s i a s m for the more physiologic operations for ulcer, this procedure has lost m u c h of its universal acceptance and appeal. F o r a distal resection to be effective, it m u s t be adequate, and most authorities believe t h a t a resection of two-thirds to three-fourths extent is necessary to produce sufficient lowering of gastric secretory activity to prevent recurrent ulceration. Such a procedure results in the sacrifice of undue gastric tissue, which will, in a sizable percentage of patients, produce undesirable long-range complications of significant degree. T h e rate of recurrent ulceration quoted in the literature, even with a d e q u a t e resection, has ranged from 1.2% to 157o 162. 166, 179, 186.2,14. 252 and the operative m o r t a l i t y from 2% to 8%. R h e a e t a/.205 found that a m o n g 182 patients u n d e l g o i n g a resection of 50-70% extent, the rate of proved recurrence was 12% and the incidence of both proved and suspected recurrence was 17%. E v e n with resections of 70-90%, the proved recurrence rate was 9% and the incidence of long-range side-effects was even greater. Postlethwait194, 195 recently r e p o r t e d 180 cases with a recurrence~ rate of 15%. T h e extent of resection varied from 60% to 75% and there were only slightly fewer recurrences following the more extensive resections. In an extensive survey depicting the results from several Veterans Administration Hospitals. Gobbel and Shoulders62 cited a recurrent ulcer rate of 12.7% a m o n g 842 patients undergoing distal resection of the Billroth II type (Fig. 1). W h e n large series of patients undergoing a d e q u a t e resection are analyzed, the incidence of excessive weight loss, anemia and nutritional deficits a p p e a r s significant. These indeed are the real criticisms of the operative procedure. Raleigh White253 p e r h a p s rightly stated that the best results with a d e q u a t e resection are obtained in healthy, robust males who are overweight preoperatively. Zollinger263 analyzed the percentages of weight loss offer various operations for ulcer and found that patients who were at or above ideal weight preoperatively fared b e t t e r following a d e q u a t e resection than did patients who were below ideal weight prior to operation. Gastric resection of the Billroth I type (Fig. 2) was a popular operation 8

WALLENSTEN - 201 ( 6 . 9 % ) MOLONEY

86 ( i . 2 % )

PALUMBO

157 ( 3 . 8 % )

FISHER, el ai HACHNIS, et ol GOBBEL and SHOULDERS

ORDHAL

9 9 (14.1%)

WELCH, C.E.

-

(4.5%)

MOORE, E D.

-

(2.8%)

OCHSNER, A.

528

(2.0%)

93 (I 1.8%) 351 ( 4 . 8 % )

8 4 2 (12.'7%)

POSTLETHWAIT

180(15%)

Ft6. 1 . ~ H e p o r t e d ulcer recurrence following a d e q u a t e gastric resection. R h e a et al.2o.',}

(Modified from

for d u o d e n a l ulcer t h r o u g h o u t E u r o p e d u r i n g the first t h r e e decades of t h e p r e s e n t c e n t u r y . It l a t e r fell into d i s r e p u t e because of the higL : a t e of recurrence, which r a n g e d from 5,% to 30%. E v e n von H a b e r e r , a s t r o n g advocate of the BiIlroth I m e t h o d , in his l a t e r y e a r s c o n d e m n e d the o p e r a t i o n for d u o d e n a l ulcer. 13ohmanson of S w e d e n was p e r h a p s the o n l y p e r s o n who never saw fit to give up the procedure. In the late 1940s, H e n r y H a r k i n s did m u c h to a w a k e n i n t e r e s t in the B i l l r o t h I m e t h o d in America. H e performed 7 0 - 8 0 % , resections for d u o d e n a l ulcer and, utilizing end-to-end g a s t r o d u o d e n o s t o m y , r e p o r t e d a r e c u r r e n t ulcer r a t e of 3.7~, a m o n g 245 patients. H e s t a t e d t h a t resections of lesser e x t e n t resulted in an increase in the r e c u r r e n t ulcer rate, a n d t h a t resections of 80% p r o d u c e d m a r k e d p o s t g a s t r e c t o m y sequelae. Several y e a r s prior to his d e a t h , H a r k i n s gave up the o p e r a t i o n a n d f o r t u n a t e l y the p r o c e d u r e was never widely e m p l o y e d by surgeons in the U n i t e d States. F r o m a s u r v e y of t h e l i t e r a t u r e d u r i n g the p a s t decade, one e n c o u n t e r s a p a u c i t y of r e p o r t s advocating a d e q u a t e distal resection.

Fro. 2 . - - A m o d e s t gastric resection of the B i l l r o t h I t y p e as ,shown without v a g o t o m y is associated with a high rate of ulcer recurrence. W i t h a r a d i c a l resection, the incidence of p a s t g a s t r e c t o m y sequelae is significant.

9

VAGOTOMY WITH DRAINAGE S h o r t l y after truncal vagotomy was reintroduced in 1943 it became a p p a r e n t to D r a g s t e d t t h a t gastric stasis was a frequent postoperative complication, and subsequent gastric drainage was required in a high percentage of patients. Later, D r a g s t e d t advocated routine juxtapyloric gastrojejunostomy as an a c c o m p a n i m e n t to truncal vagotomy. Gastrojejunostomy thus became the preferred method of draining the vagotomized stomach until the early 1950s, when Weinberg popularized pyloroplasty. Currently, most surgeons prefer either a Weinberg, Finney or J a b o u l a y type of pyloroplasty as a m e t h o d of gastric drainage. T h e r e is no doubt t h a t the popularity of truncal vagotomy-pyloroplasty has increased greatly since its inception more than 20 years ago, and its popularity has grown in recent years. This is "evidenced by the increasing n u m b e r of reports a p p e a r i n g in the surgical literature. Currently, there are those who advocate the operation routinely for duodenal ulcer, whereas others prefer the procedure only in selected cases, such as the high-risk patient, the individual with severe i n f l a m m a t o r y reaction around the duod e n u m and particularly the elderly individual with massiw.• bleeding who it is believed will not stand a procedure of greater magnitude. T h e proponents of truncal vagotomy-pyloroplasty believe that pyloroplasty is a subtle, safe and effective method of achieving a n t r e c t o m y with the advantages of less morbidity and less risk to life when compared to distal resection. T h e y strongly emphasize the importance of the low operative mortality rate, and readily accept an increased rate of recurrent ulceration. F r o m a critical appraisal of the outstanding articles published and communications received during the past decade it is readily a p p a r e n t that there exists a wide discrepancy of opinion concerning the merits, as well as the results, of vagotomy-pyloroplasty as a method of t r e a t m e n t of duodenal ulcer.22.39.193.222,249-251,261 MeadlTa reported 148 patients operated on, including both elective and emergency cases, with a m o r t a l i t y of only 2%. Five r e c u r r e n t ulcers, however, developed over a short follow-up period (3% incidence of recurrence), Feggetter and Pringle55 foliowed 248 patients for 10-14 y e a r s after vagotomy with drainage and concluded that the operation was safe and relatively free from side-effects. Only 1 death occurred following the procedure, but 12 patients (5%) required reoperation for either a proved recurrent ulcer or a recurrence of tflcer-like symptoms, Schofield e t al.21s expressed satisfaction with vagotomy-pyloroplasty and emphasized its ease of execution, relative safety and freedom from hematologic and metabolic effects. I n their opinion, these advantages compensated for a r e c u r r e n t ulcer rate of between 4.2% and 6.6%. Eisenberg e t al..4,~ in an excellent retrospective study of 455 patients, cited an elective m o r t a l i t y rate of less than I/e/o, a m o r t a l i t y of only 1.85% following emergency operation and an over-all recurrence rate of 3.6% during an average follow-up of 7 years. Only rarely were serious d u m p i n g problems or diarrhea encountered, and 80% of the patients m a i n t a i n e d an ideal weight. Evans et a/..15 cited 527 patients who u n d e r w e n t vagotomy ;vith drainage at The University of Chicago Hospi*~als with an operative :mortality of only 0./6,0 and a subsequent recurrent ulcer rate of 7.6?o. Pyloroplasty was thought to be superior to gastroenterostomy as a method of drainage. One of the most thorough studies has been that by Thompson, 2,~ who, in a recent l0

communication to me, stated t h a t he had performed vagotomy-pyloroplasty on 647 patients between J u l y of 1963 and J a n u a r y of 1971 with an over-all mortality of 1.2%. T h e mortality following elective operation was 0,3% and the mortality after emergency operation was 5.6%. T h e rate of recurrent ulceration thus far has been only 3%. D u m p i n g s y m p t o m s and nutritional deficits have created only an occasional problem. Small and Jahadi~25 reported 137 patients with an over-all operative m o r t a l i t y of 0.7%. T h e mortality following operation for massive hemorrhage was only 3.8?o and the over-all recurrent ulcer rate was 7.2%. Small and Jahadi believed that the recurrences were due primarily to technical errors in performing either vagotomy or pyloroplasty. M c D o n a l d and Abt:ahil;1 cited 500 patients with a follow-up ranging from 2 to 8 years. The ulcer diathesis was controlled in 84% of the patients. The over-all operative mortality was 4.2%. The death rate following operation to control massive hemorrhage was 24% in contrast to a mortality of 0.4% in elective operations. T h e proved recurrent ulcer rate was 2,2%. Savage and McVay2]3 described a m o r t a l i t y of 10.7% among patients who u n d e r w e n t operation for massive hemorrhage and an over-all surgical mortality of 2.7%, T h e proved and suspected ulcer rate was 4.87~ among 211 patients followed for 1-19 years. Go]igher et ai.64, 65 have observed a 6.3% rate of recurrence over a 3-year follow-up period, and recently Stemmer23Z informed me t h a t among 1,000 patients studied by him and Weinberg the recurrent ulcer rate has been 10% (Fig. 3). Dorton,36 in a personal communication, states that over a 25-year period he has performed vagotomy-pyloroplasty in slightly over 1,000 patients. Only 9 hospital deaths occurred, including deaths following emergency operation for bleeding, for an over-all m o r t a l i t y of 0 .9/b. D u r i n g the first 10 y e a r s of his clinical study, the recurrent ulcer rate was 8.8,%, but during the past 15 years, among roughly 800 patients, the recurrent rate has been just under 2a~',. Dorton ascribes this improvement to his ability to carry out .

FIG. 3.--Ileporte(l ulcer recurrence following truncal vagotomy-pyloroplasty.

WEINBERG

10%

DRAGSTEDT

7%

MEADE

3%

FEGGETTER

5%

HERRINGTON

1"7%

SCHOFIELD

6.6%

GRIFFEN

23.4%

EISENBERG

3.6%

PRICE

THOMPSON

3%

LYNCH

FARRIS

3%

GOLIGHER

SMALL

7.2%

JUDD

McVAY

]l

4,8%

8.9% I3% 6.:3% i I.I %

SATISFACTORY RESULTS ~

~ 7 DUMPING ~ o ~ = . ,

SYMPTOMS

RECURRENT ULCERATION

F_~/~.~~]

~

0

%

¢"J ,o

!7%

WEIGHT ~ I 0 % LOSS MORTALITY FIG. 4 . ~ T h e author's current results with truncal vagotomy-pyloroptasty.

a more complete truncal vagotomy and to a change from the HeinekeMikulicz to a F i n n e y pyloroplasty3T F a r r i s and Smith, in a large clinical experience n u m b e r i n g a p p r o x i m a t e l y 800 patients, likewise cite a recurrent ulcer rate of 3,% and over-all satisfactory results.53, 5,1 Thus, m a n y of the authorities advocating v a g o t o m y - p y l o r o p l a s t y acknowledge an ulcer rec u r r e n t rate ranging from 2% to 10%, but believe that the low morbidity, low m o r t a l i t y and over-all patient satisfaction in 85-90% of cases are eloquent tributes t o the operation. D u r i n g a 10-year period ending in 1968, our group performed truncal vagotomy-pyloropIasty on 260 patients (Fig. 4). T h u s far, there has occurred a 1 7 ~ incidence of r e c u r r e n t ulceration. A m o n g the 44 patients with r e c u r r e n t ulcer, the vast m a j o r i t y had a complete truncal vagotomy, as evidenced by the H o l l a n d e r test or proved at subsequent reoperation. Likewise, the pyloroplasty was a d e q u a t e in each case and antral stasis could not be incriminated as a factor in producing recurrence. T h e dumping s y n d r o m e has occurred in 25% of patients, but anemias and weight losses have l~ot posed a preblem. Our operative m o r t a l i t y rate has been 5% among the 260 patients, and this high death rate c a n be a t t r i b u t e d to the poor-risk status of m a n y of the patients, who comprised an elderly age group. Both Lynch et al.1*;o and J u d d et al.133 have reported r e c u r r e n t ulcer rates exceeding 10% and satisfactory results in only 75% of patients a f t e r tl;uncal vagotomy with pyloroplasty, Griffen likew,~se has experienced poor results with vagotomy and gastric drainage. In a recent communication to me,TS he states that between 1962 and 1965 the operation was performed on 115 patients at the University of K e n t u c k y I-Iospital. All were elective operations: 105 patients underwent pyloroplasty ~_~s the drainage procedure and 10 u n d e r w e n t gastroenterostomy. To date, 27 recurrent ulcers have o c c u r r e d , 20 in the pyloroplasty group and 7 following gastroenterostomy, for a total recurrence rate of 23.4%. T h e average time interval prior to the development of recurrent ulceration has been 20 months, but Griffen has observed the onset of recurrent ulcer s v m p t o m s 4-5 ye~trs followi:lg operation. A similar observation has been experienced by our group. A 70% incidence of rec , r r e n t uh'er following v n g o l o m y . g a s t r o e n t e r o s t o m y (Fig. 5) has been of of great concern to Griffen,79 but a series of 10 patients is indeed small and renders evaluation difficult. Other surgeons in America, however, 19

F~6. 5 . ~ T r u n c a l vagotomy with gastroentero.stomy currently is used only in selective circumstances, particularly when dealing with a large inflammatory ma~s around the d u o d e n u m that precludes resection or pyloroplasty.

have noted a high r e c u r r e n t ulcer rate with this m e t h o d of gastric drainage. G a s t r o e n t e r o s t o m y has several d i s a d v a n t a g e s as a d r a i n a g e method. T h e s h u n t promotes the release of a n t r a l gastrin, the j e j u n u m is more susceptible to ulceration t h a n is the d u o d e n u m , a n d with gastroenterostomy tile duodenal-acid brake on gastric secretion is largely lost. W e employ g a s t r o e n t e r o s t o m y only w h e n an intense i n f l a m m a t o r y process is e n c o u n t e r e d a r o u n d the d u o d e n u m , which would r e n d e r resection hazardous and pyloroplasty impossible. British surgeons, on the o t h e r hand, do not recognize a g r e a t e r incidence of recurrence with g a s t r o e n t e r o s t o m y when conapared to pyloroplasty, but readily acknowledge t h a t such lrat i e n t s have considerably m o r e long-range postoperative sequelae, such as bilious vomiting and s y m p t o m s of the d u m p i n g syndrome. C u r r e n t l y , most surgeons prefer a F i n n e y or d a b o u l a y pyloroplasty (Fig. 6) as a m e t h o d of drainage, believing t h a t these procedures provide m o r e a d e q u a t e drainage, since each is p e r f o r m e d t h r o u g h relatively u n s c a r r e d d u o d e n u m in c o n t r a s t to the \Veinberg method. Lulu et a1.159 showed in the experim e n t a l a n i m a l t h a t there was no p a r t i c u l a r a d v a n t a g e with any one of the t h r e e different pyloroplasties, but they were o p e r a t i n g on a n i m a l s with n o r m a l d u o d e n u m s . It is both difficult a n d f r u s t r a t i n g to a t t e m p t to explain the wide discrepancies in results a m o n g the r e p o r t e d series of patients. It seems unlikely t h a t faulty technic in p e r f o r m i n g t r u n c a l vagotomy or in constructing a p y l o r o p l a s t y could be responsible for most recurrences, as some of the poorest results have been reported by surgeons who have had both wide clinical a n d l a b o r a t o r y experience in gastric surgery. It is well appreciated t h a t patients have developed r e c u r r e n t ulceration despite a proved complete vagotomy a n d a d e q u a t e pyloroplasty. Likewise, it is. known t h a t a pyloroplasty does not nullify the liberation of anfrai gastrin, a n d such p a t i e n t s continue to secrete acid, p a r t i c u l a r l y d u r i n g the phase of digestion. Indeed, following gastric p a r a s y m p a t h e t i c d e n e r v a t i o n , a n t r a l gastrin inhibition is largely destroyed. In c o m p a r i n g four d i f f e r e n t operative procedures for ulcer, Price et al. tbund truncal vago/omy and pyioroplasty to be the least effective in reducing free hydrochloric acid 13

-1 ~J4-'ANTERIOR TRUNK

FINNEY

',

JABOULAY

Fro. 6 . - - S k e t c h e s depicting selective v a g o t o m y with pyloroplasty.

u n d e r both fasting a n d s t i m u l a t o r y conditions. Also, it has been demons t r a t e d recently t h a t t r u n c a l v a g o t o m y is less effective t h a n selective vagotomy in p r o d u c i n g complete gastric denervation. E v a l u a t i o n a n d c o m p a r i s o n of the r e p o r t e d retrospective studies a r e difficult due to differences in age groups, severity of ulcer disease and v a r i a t i o n s in experience a m o n g surgeons. Possibly with prospective rand o m i z e d studies a n d by c o m p a r i n g o t h e r o p e r a t i o n s for ulcer a n d utilizing large n u m b e r s of p a t i e n t s can the t r u e s t a t u s of t r u n c a l v a g o t o m y and p y l o r o p l a s t y be ascertained. T h e one such s t u d y using four different operations for ulcer recently r e p o r t e d by Price et al.203 showed v a g o t o m y and p y l o r o p l a s t y to result in t h e lowest m o r t a l i t y a n d t h e highest rate of recurr e n t ulceration. S t a t i s t i c a l l y significant differences a m o n g the four operations were found at less t h a n t h e 0.05 level in i m p o r t a n t postoperative characteristics. S e l e c t i v e vagotomy a n d p y l o r o p l a s t y has for a n u m b e r of years been a

p o p u l a r a n d widely used o p e r a t i o n t h r o u g h o u t G r e a t B r i t a i n a n d Europe.6, 165. 210, 211 I n America, however, the use of the selective technic has b e e n largely r e s t r i c t e d to c e r t a i n medical centers, a n d t h e vast m a j o r i t y of clinical s u r g e o n s h a v e favored the t r u n c a l operation. T h e late H e n r y H a r k i n s , along with C h a r l e s Griffith, did the m o s t to p o p u l a r i z e the selective technic in the U n i t e d States, a n d their studies have constituted an o u t s t a n d i n g c o n t r i b u t i o n to the a n a t o m y , physiology a n d o p e r a t i v e app r o a c h to the gastric vagi.S2, 83, s5,204,231 T h e s e authors, along with others who p r e f e r selective vagotomy, e m p h a s i z e the completeness of gastric den e r v a t i o n t h a t is obtained with the technic, a n d stress the i m p o r t a n c e of p r e s e r v a t i o n of the h e p a t i c a n d celiac i n n e r v a t i o n to the gallbladder, pancreas, small i n t e s t i n e a n d proximal colon for the p r e v e n t i o n of d i a r r h e a and o t h e r g a s t r o i n t e s t i n a l sequelae. It is well k n o w n t h a t biliary t r a c t motility is u n d e r the influence of both h o r m o n a l a n d neural control. T h e n e u r a l influence m e d i a t e d by the 14

hepatic vagi maintains m u s c u l a r tonus, and transection of the hepatic vagal branch in truncal vagotomy invariably has resulted in dilatation of the gallbladder. Such a finding does not occur following the selective operation. Delayed e m p t y i n g of the gallbladder, a loss of contractile response and an increased incidence of gallstones have been reported with the truncal operation.31,114,177, ls4 White and McGee2n5 have shown a decreased pancreatic response toi secretin following truncal vagotomy but no such change after the selective operation. K r a f t e t a1.144 demonstrafed a loss ~t insulin response a f t e r truncal vagotomy, and White and ButlerZn'z observed a decrease in feeding response of 24-hour output of pancreatic juice. T h e celiac vagi m a i n t a i n the m u s c u l a r tonus of the small intestine and right colon. Transection of the celiac vagi ira truncal vagotomy m a y result in prolonged midgut ileus. Ballinger has reported a t r o p h y of the mucosa of the small intestine persisting up to 21 weeks following truncal vagotomy. Mucosal inflammation and reduction in the size of intestinal villi have been observed also, but such changes have been transient. A temporary decrease in blood flow in the venous system draining the small intestine likewise has been described.l:t-16 Diminished fat absorption following truncal vagotomy lms been cited by White and Butler.ZS~ Most, but not all, of the above observations have been carried out in the experimental animal, and there are m a n y observers who believe t h a t these findings, although of great interest, cannot be transferred to the clinical situation to show t h a t selective vagotomy is superior to truncal vagotomy. Today, D r a g s t e d t remains firmly convinced that the biliary a p p a r a t u s and pancreas are p r e d o m i n a n t l y under hormonal and not neural control. K r a f t et al.. 1'i5 in a comparative clinical study of patients subjected to selective and to truncal vagotomy, showed no significant difference ira fecal fat and nitrogen excretion or in gallbladder and small intestinal motor function. No relationship existed between postvagotomy d i a r r h e a and steatorrhea. Baldwin e t al.. t''- studying the metabolic and nutritional effects of the two procedures, found essentially no difference, but the ability of selective vagotomy to achieve complete gastric denervation was confirmed. Essentially the same conclusions were reached by Crow and his group3J at Milwaukee. In a rigid laboratory appraisal, Dignan35 found the selective operation to result in a more adequate vagotomy. K r a f t e t al. li6 in a clinical study, showed t h a t selective vagotomy did not lessen the incidence of postvagotoray diarrhea. Similar observations have been reported by Smith and Farris,'-'26, 227 who believe that the selective technic does not justify the added operative time and effort. Sawyers e t ai.,214 in a,prospective randomized clinical s t u d y totaling 145 patients, compared the effects of truncal and selective vagotomy. T h e incidence of d i a r r h e a and other abdominal complaints was not significantly different between the two groups, but selective vagotomy was superior to truncal vagotomy in obtaining complete vagal denervation of the stomach (19% incidence of incomplete vagotomy with the truncal opera/ion as compared to a 2°0 incidence with the selective technic using Hollander's criteria). More recently, Sawyers and Scott21,~ reported the prel i m i n a r y results of a prospective randomized study including only elective patients, which suggested t h a t selective vagotomy and pyloroplasty afforded patients as good a clinical result as did selective vagotomy with 15

a n t r e c t o m y . This was c o n t r a r y to the past experience of superior clinical results with truncal vagotomy and a n t r e c t o m y compared to truncal vagotomy and pyloroplasty. GritfithS0 has possibly the most carefully studied series of patients subjected to selective vagotomy and pyloroplasty in the United States. A m o n g 130 patients operated on between 1963 and 1968 and studied to the present time, he has observed no bona fide r e c u r r e n t ulcer. One patient, however, has bled during t h e remote postoperative study. T h i s patient has free basal acid, a negative insulin test and a normal u p p e r gastrointestinal b a r i u m study. A second patient has developed typical ulcer-liFe symptoms, but all studies have remained normal. In addition, Griffith has participated in the surgical care of 70 other patients who have undergone selective vagotomy-pyloroplasty. T h r e e recurrent ulcers have developed in this group. One was due to an incomplete gastric vagotomy, one to an i n a d e q u a t e pyloroplasty with stasis a n d a third patient d e m o n s t r a t e d antral h y p e r f u n c t i o n postoperatively as described by Kay. Amdrup5 has observed a 3.5/a-~ recurrence rate with selective vagotomy and pyloroplasty. Currently, it a p p e a r s to be the consensus a m o n g most observers that the greatest asset offered by selective vagotomy is the degree of completeness of gastric denervation.47,6z, 11~, 134,151,155 T h e decreased incidence of d i a r r h e a and other vagotomy sequelae a p p e a r s to be much less impres sive. P r e s e n t l y , the operation seems to be indicated largely in elective situations, rarely u n d e r emergency conditions and preferably a m o n g candidates who do not present a problem as regards obesity. T h e technic of selective vagotomy in combination with pyloroplasty a p p e a r s to give added protection over truncal vagotomy in respect to the likelihood of recurrent ulceration.

VAGOTOk~IY AND CONSERVATIVE RESECTION Bilateral truncal vagotomy combined with a modest distal resection was first performed by F a r m e r and Smithwick49. nl of Boston in October of 1946, w h e n operating on a patient who had developed a marginal ulcer following simple gastroenterostomy. T h e y dismantled the gastroenterostomy, perfornied bilateral truncal vagotomy, resected an estimated 50% of the distal stomach and the duodenal bulb and constructed a retrocolic H o f m e i s t e r t y p e anastomosis. T h e y t e r m e d the resection a hemigastrectomy. I n J a n u a r y of 1947, L e o n a r d Edwards41 of Nashville, u n a w a r e of Smithwick's case, performed a bilateral truncal vagotomy with an estim a t e d 40% distal resection and a retrocolic gastroenterostomy on a physician with an obstructing duodenal ulcer. E d w a r d s t e r m e d the resection a n antrectomy. In N o v e m b e r of 1947, H. D a i n t r e e Johnson of the Royal F r e e H o s p i t a l in London carried out bilateral truncal vagotomy with an estimated 50% distal resection for a complicated duodenal ulcer. H e later reported his p r e l i m i n a r y work before the Royal College of Medicine. At present, this operation continues to be his procedure of choice f o r duodenal ulcer.115-~24, 18s Following the initial reports of these clinical investigators, interest in the operation grew steadily, and over the ensuing years the combined procedure became widely accepted. It was a p p r e c i a t e d early t h a t the procedure not only could be applied to the patient undergoing elective opera16

tion but also was readily adaptable to the massive bleeder, to the patient with obstruction and even to selected cases of acute ulcer perforation. T h e physiologic concept behind the operation was indeed s o u n d - - t h e elimination o f the cephalic phase of gastric secretion by vagotomy and the removal of the hormonal or gastrin phase by antral excision. T h e patient was left with a sizable gastric remnant, and it was the hope that this physiologic operation would largely obviate the m a n y undesirable long-term sequelae seen so frequently in patients who had been subjected to a d e q u a t e gastric resection. I n t e r i m reports by us and others40, ~J2,9_%22s indeed suggested that the operation was extraordinarily effective in preventing recurrent ulceration. The long-term ill effects were comparatively small and excessive weight losses and n u t r i t i o n a l deficits did not pose a particular problem. T h e m a i n criticism of the operation throughout the years has been the m o r t a l i t y rate, which has averaged around 1.5-2°~. One of the most complete and comprehensive retrospective studies has been published by T h o r o u g h m a n et al.24o based on an analysis of 504 patients undergoing truncal vagotomy and h e m i g a s t r e c t o m y . T h e over-all operative mortality was 1.59%. For patients undergoing elective operation, the m o r t a l i t y was 0.54% and the m o r t a l i t y for emergency bleeding pafienls was 5°.o. Among the patients operated on for hemorrhage, obstruction and perforation, more than 9 0 ~ in each group experienced longterm satisfactory results. Among 134 patients who were operated on for intractable pain. 89q~, experienced long-term satisfactory results. Only two recurrent ulcers developed among the 504 patients over a 2,14-year follow-up (incidence of 0.4%~). and each r e c u r r e n c e w a s due to an unrecognized Zollinger-Ellison tumor. Of extreme-.interest in the T h o r o u g h m a n et al. s t u d y was that more than 90ao of the postoperative patients were achlohydric to histamine stimulation. T h e y believed that patients with appreciable free hydrochloric :acid represented those with an incomplete vagotomy. Postoperative weight losses occurred in only 26.5~o of patients and in most instances the loss was due to a chronic debilitating illness and not the direct result of vagotomy-gastrectomy,. D i a r r h e a occurred in 4.1% of patients but was severe in only 1 patient. S y m p t o m s of the d u m p i n g s y n d r o m e of m o d e r a t e or severe degree were present in 10.5°~. T w e n t y - o n e per cent of patients had a long-range postoperative h e m o g r a m below !2.5, as compared to 41 of patients with a h e m o g r a m below 12 who had undergone adequate subtotal gastric resection alone. T h o r o u g h m a n believed that the combined operation, although not entirely solving the problems of diarrhea, anemia: dumping and nutrit.;,on, did have certain d e f i n i t e advantages over adequate gastric resection. Currently. his enthusiasm for the operation is even greater than at the time of the retrospective report. 24l Palumbo~S9 has utilized an operation consisting of bilateral truncal vagotomv with an estimated ,.5,o o distal resection and a Billroth II type reconstruction. This is basically the procedure described by both Sm'ithwick and E d w a r d s except that the proximal extent of resection is slightly less. T h e antral segment is variable in extent and perhaps in m a n y cases P a l u m b o does indeed remove the entire antral segment. H e is careful to c a r r y his dissection beyond the pylorus so t h a t no distal a n t r a l tissue remains. It is well appreciated that in a 13illroth I I type resection, a small o

.

17

s e g m e n t of distal a n t r u m left a t t a c h e d to t h e closed d u o d e n a I s t u m p creates an ulcerogenic situation. A small s e g m e n t of r e t a i n e d proximal ant r u m usually p r e s e n t s no p a r t i c u l a r problem. W i t h a Billroth I resection, a small r e t a i n e d s e g m e n t of e i t h e r p r o x i m a l or distal a n t r u m in continuity w i t h t h e d u o d e n u m is~n0t t h o u g h t to be ulcerogenic. T h i s l a t t e r concept, however, recently was q u e s t i o n e d by H a r r i s o n a n d Stoller,94 who showed e x p e r i m e n t a l l y t h a t v a g o t o m y a n d i n c o m p | e t e proximal antrect o m y reduced gastric secretion by only 40%. I n a recent personal c o m m u n i c a t i o n , Palumbo190 states t h a t from J a n u ary, 1952, t h r o u g h S e p t e m b e r , 1970, he p e r f o r m e d t r u n c a l v a g o t o m y with distal a n t r e c t o m y in 585 cases. F o u r t e e n d e a t h s occurred a m o n g this group (2.4% m o r t a l i t y ) , 11 following elective o p e r a t i o n a n d 3 following e m e r g e n c y operation. T h e m o r t a l i t y a m o n g 406 p a t i e n t s u n d e r age 60 was 1.5%; a m o n g 179 p a t i e n t s over 60 y e a r s of age it was 4.5,~o. A m o n g 48 p a t i e n t s u n d e r g o i n g o p e r a t i o n as a n e m e r g e n c y for massive bleeding, the m o r t a l i t y (3 d e a t h s ) was 6.2%. T h e r e was but 1 d e a t h a m o n g 26 p a t i e n t s below age 60 who u n d e r w e n t emergeIicy o p e r a t i o n ( m o r t a l i t y 3.8..~0). T h e cause of d e a t h in t h e 3 p a t i e n t s was c a r d i o p u l m o n a r y complications. T h e r e was no evidence of significant p o s t o p e r a t i v e rebleeding. A m o n g the 11 patients who e x p i r e d following elective operation, 4 died as a result of acute p a n c r e a t i t i s , p r o b a b l y i n i t i a t e d by o p e r a t i v e technical problems. T h e rem a i n i n g 7 d e a t h s were d u e largely to c o r o n a r y disease or p o s t o p e r a t i v e infection. Follow-up h a s b e e n available on.508 of t h e 585 p a t i e n t s over a 1-19-year period. One h u n d r e d f o r t y - t h r e e of the g r o u p have been observed from 8 to 19 years. T h e r a t e of r e c u r r e n t u l c e r a t i o n a m o n g the 508 p a t i e n t s has been 0.5%. Only 17.3.°7o of p a t i e n t s have lost weight since operation, a n d weight losses have not b e e n excessive. S e v e r e d u m p i n g has bee~. a p r o b l e m in 0.4% of patients, a n d d i a r r h e a of signxificant d e g r e e has been e x p e r i e n c e d by 3.3%. N i n e t y - s i x a n d one-half per cent of p a t i e n t s have no free h y d r o c h l o r i c acid in the residual gastric pouch after fasting a n d following h i s t a l o g ' s t i m u l a t i o n . T h e insulin test h a s r e m a i n e d n e g a t i v e in m o r e t k a n 90% of patients. Jordan,13'-, ls2 in a r e c e n t r a n d o m i z e d study, showed t h a t vagotomya n t r e c t o m y was s u p e r i o r to lesser p r o c e d u r e s as the o p e r a t i o n of choice in the m a j o r i t y of p a t i e n t s because of t h e lower r e c u r r e n t ulcer r a t e w i t h o u t FIG. 7 . - - A , sketch depicting truncal v a g o t o m y - a n t r e c t o m y and Billroth I[ reconstruction. B, truncaI v a g o t o m y . a n i r e c t o m y and BiIiroth I recoristruction.

18

a n association of i n c r e a s e d m o r b i d i t y a n d m o r t a l i t y . O n l y in difficult technical cases w h e r e the risk was high did he believe the c o m b i n e d o p e r a t i o n unjustifiable. In a r e c e n t r a n d o m i z e d s t u d y c o n d u c t e d t h r o u g h the c o o p e r a t i o n of 17 V e t e r a n s A d m i n i s t r a t i o n H o s p i t a l s , it was found t h a t of four different o p e r a t i v e p r o c e d u r e s for ulcer, v a g o t o m y - a n t r e c t o m y gave s u p e r i o r results as r e g a r d s recurrence.203 F a r m e r ~,0 a n d Smithwick,22'J in recent u n p u b l i s h e d d a t a s u b m i t t e d to me, s t a t e t h a t since October, 1946, 752 p a t i e n t s have u n d e r g o n e vagotomyh e m i g a s t r e c t o m y on t h e i r services with a m o r t a l i t y of 1.9%. T h i s includes p a t i e n t s o p e r a t e d on as a n e m e r g e n c y for h e m o r r h a g e . S o m e of the e a r l i e r p a t i e n t s o p e r a t e d on by S m i t h w i c k have since died, but F a r m e r has followed 622 p a t i e n t s from ] to over 22 years. T h e r e c u r r e n t ulcer r a t e a m o n g the l a t t e r group has been 1.4%. A m o n g the 15 p a t i e n t s with recurr e n t ulcer, 14 were due to proved i n c o m p l e t e v a g o t o m y ( u s u a l l y an overlooked right nerve t r u n k ) , a n d 1 was caused by a Zollinger-Ellison tumor. E a c h of the r e c u r r e n c e s took place within 2 y e a r s following operation, a n d a d d i t i o n a l r e c u r r e n c e s h a v e n o t shown up with ~he passage of time. T h e over-all clinical results have been excellent, a n d F a r m e r believes t h a t v a g o t o m y w i t h h e m i g a s t r e c t o m y is the p r e f e r r e d o p e r a t i o n u n d e r m o s t c i rcumstances. 52 B e g i n n i n g w i t h the clinical work of the late L e o n a r d E d w a r d s e a r l y in 1947, our surgical group a t t h e V a n d e r b i l t U n i v e r s i t y affiliated hospitals h a s c o n t i n u e d to show an e v e r - i n c r e a s i n g e n t h u s i a s m for v a g o t o m y a n t r e c t o m y {Fig. 7). O v e r a 22-year period ending D e c e m b e r , 1969, we p e r f o r m e d the combined o p e r a t i o n on a total of 3,000 p a t i e n t s w i t h complications of duodefial ulcer. T h e ages r a n g e d from 8 to 94 y e a r s , w,:th the largest n u m b e r of p a t i e n t s being between ages 35 a n d 50. T h e ratio of m a l e s to females was 6 : 1 . F i f t y - t h r e e p e r c e n t of the e n t i r e series w e r e o p e r a t e d on for i n t r a c t a b l e pain. E i t h e r a s i n g l e l i f e - t h r e a t e n i n g h e m o r r h a g e or r e p e a t episodes of bleeding c o n s t i t u t e d the indication for operation in 30%. T h i r t e e n p e r cent of p a t i e n t s were o p e r a t e d on for gastric o u t l e t o b s t r u c t i o n a n d 4% u n d e r w e n t definitive o p e r a t i o n for an a c u t e ulcer p e r f o r a t i o n (Fig. 8). T h e over-all o p e r a t i v e m o r t a l i t y in t h e series was 1.7% (49 d e a t h s ) . T h i r t y p a t i e n t s died following o p e r a t i o n for massive h e m o r r h a g e , a n d the m a j o r i t y of this group were p a t i e n t s of a d v a n c e d age. M o s t h a d received f r o m 8 to 20 u n i t s of blood p r i o r to t r a n s f e r to o u r i n s t i t u t i o n s or p r i o r to t h e i n t e r n i s t ' s seeking surgical consultation. S u r ~ c a l i n t e r v e n t i o n e a r l i e r Fro. 8.wIndications for operation among 3,000 patients undergoing truncal vagotomyantrectomy.

INTRACTABLE PAIN

~

5

3

% :3O%

HEMORRHAGE

OBSTRUCTION PERFORATION ]9

3O

12 erly

MASSIVE BLEEDING

ASSOCIATED DISEASE

TECHNICAl_ ERROR

Fro. 9 . ~ O p e r a t i v e m o r t a l i t y (49 deaths I1.7 o-o]) in 3,000 patienls.

in the course of bleeding or, in several instances, the use of a m o r e conservative surgical o p e r a t i o n could have salvaged several of these patients. S u c h significant associated diseases as r h e u m a t o i d arthritis, cardiopulmon a r y p r o b l e m s a n d severe diabetes p l a y e d a d o m i n a n t role in leading to early p o s t o p e r a t i v e d e a t h in 12 patients. Seven p a t i e n t s e x p i r e d in the p o s t o p e r a t i v e period as the result of a technical operative e r r o r t h a t should n e v e r h a v e occurred (Fig. 9). It is of i n t e r e s t t h a t o u r over-all m o r t a l i t y rate has steadily declined as the result of a d d i t i o n a l experience with the combined o p e r a t i o n a n d ti:rough rigid case selection with t h e utilization of a lesser surgical operation in selected circumstances. T h e p r e s e n t over-all m o r t a l i t y r a t e of 1 . 7 a~ • ,o is a decided i m p r o v e m e n t over a r a t e of 2.7ffo a m o n g 1,127 p a t i e n t s t r e a t e d t h r o u g h 1961. T h i s decline in m o r t a l i t y , however, was becoming a p p a r e n t in 1966 w h e n the series at t h a t time n u m b e r e d almost 2,000 p a t i e n t s with an over-all m o r t a l i t y of 2.3%. C u r r e n t l y , the m o r t a l i t y for elective operation is just u n d e r 1%, a n d a m o n g the g r o u p of p a t i e n t s u n d e r g o i n g emergency o p e r a t i o n for massive h e m o r r h a g e ; the d e a t h rate has been 6/o. o~ E i g h t e e n p e r cent of the 2,951 surviving p a t i e n t s experienced significant Imstoperative complications consisting largely of severe w o u n d infection, leakage from the d u o d e n a l s t u m p , c o r o n a r y thrombosis, thrombophlebitis, p u l m o n a r y embolism a n d d e l a y e d gastric emptying.97-10a. 2t9-221 Acute postoperative p a n c r e a t i t i s with severe clinical m a n i f e s t a t i o n s was experienced by only 4 patients. T h i s l a t t e r complication, a l t h o u g h cited as being a not i n f r e q u e n t a f t e r m a t h of gastric resection, occurred rarely despite o u r being c o g n i z a n t of its possible development. It was n o t u n u s u a l , however, to observe a rise in s e r u m a m y l a s e values for several days postoperatively in p a t i e n t s who were e x p e r i e n c i n g an otherwise s m o o t h p o s t o p e r a t i v e course. T h i s rise in s e r u m a m y l a s e a l m o s t invariably o c c u r r e d in those patients who h a d severe d u o d e n a l p a t h o l o g y a n d who p r e s e n t e d difficult technical problems. S t o m a l o b s t r u c t i o n took place in 5% of p a t i e n t s during the early p o s t o p e r a t i v e period, a n d r e o p e r a t i o n was necessary in approximately one-half of this group. A m o n g the e n t i r e series of 3,000 p a t i e n t s only 10% h a v ' e lost weight to a level t h a t is considered to be a significant loss for the individual. E i g h t y 20

per cent of patients have either m a i n t a i n e d their ideal weight or noted weight gains. V a s o m o t o r a n d gastrointestinal s y m p t o m s of mild to moderate degree h a v e been experienced by 25% of p a t i e n t s d u r i n g the longrange follow-up. M o s t p a t i e n t s can largely control these troublesome s y m p t o m s t h r o u g h avoidance of certain foods and by following simple instructions. In 1°7o of patients, s y m p t o m s of the d u m p i n g s y n d r o m e have been severe and refractory. D i a r r h e a is a r a t h e r f r e q u e n t complication in 10-50% of p a t i e n t s during the early p o s t o p e r a t i v e period, b u t in m o s t instances it d i s a p p e a r s in several weeks. P e r s i s t e n t d i a r r h e a of mild to moderate degree consisting of two to four loose or poorly f o r m e d stools per d a y has been experienced by 10% of patients. T h i s has been no great cause for a l a r m , however, a n d most patients have not considered it a problem. S e v e r e d i a r r h e a has been experienced by 1% of p a t i e n t s (Fig. 10). Follow-up studies have been complete in 99% of the 3,000 cases. S o m e of the earlier patients, p a r t i c u l a r l y a m o n g those o p e r a t e d on by E d w a r d s , have since died of u n r e l a t e d causes. However, each p a t i e n t was followed until the time of d e a t h a n d has been included in the c u r r e n t studies. A m o n g the 3,000 patients, 68% have been j u d g e d by several observers to have obtained an excellent clinical result. P a t i e n t s m u s t be s y m p t o m - f r e e in all respects to fit into this category. T w e n t y - s i x per cent of patients have been m a r k e d l y improved and express e x t r e m e satisfaction with the o p e r a t i o n but experience mild a b d o m i n a l fullness, i n f r e q u e n t belching and occasional d i a r r h e a . Five per cent of p a t i e n t s have significant postoperative c o m p l a i n t s as fullness, vague discomfort and m o d e r a t e vasomotor disturbances. W e i g h t loss generally has been experienced by this group. E a c h p a t i e n t has been in,proved as c o m p a r e d to the p r e o p e r a t i v e status, but the clinical result is d e e m e d only fair. One p e r cent of p a t i e n t s have received no benefit from the operation, a n d this group also comprises those who ha,,,'e developed r e c u r r e n t ulcers (Fig. 11). O u r experience has paralleled t h a t of others in t h a t vagotomy-antrectomy has been highly effective in p r e v e n t i n g r e c u r r e n t ulceration. Indeed. most gastric surgeons c u r r e n t l y believe t h a t the o p e r a t i o n provides g r e a t e r a s s u r a n c e against r e c u r r e n c e w h e n c o m p a r e d to o t h e r o p e r a t i o n s in curFzG. lO.--Incidenee of early complications and long-,erm sequelae following tile combined operation in 3.000 patients.

N O N - FATAL

A NEMIAS

HOSPITAL COMPLICATIONS

Rore

IB% POST-OPERATIVE WEIGHTS Lost Gained

IO% IO %

Ideal

80%

DUMPING S Y M P T O M S

DIARRHEA M i l d to Moderate " Severe

IO%

Mild to Moderote~

1%

Severe "

21

25 % I-2

%

EXCELLENT

68%

GOOD 26%

FAIR 5%

POOR ,,,

I%

Fro. ll.---Results with truncal v a g o t o m y - a n t r e c t o m y (3,000 patients).

rent use. U p to J u n e , 1971, only 16 proved recurrent ulcers have taken place a m o n g the entire series (incidence of 0.6%). T h e r e are no additional patients in whom a recurrence ]s s u s p e c t e d but unprow.,d. In keeping with F a r m e r ' s observations, each of our recurrences became manifest during the first 24 m o n t h s following operation. T h e fact that recurrences have not t a k e n place during the long-range follow-up is an added credit to the operation. More t h a n 1,000 patients have now been carefully foIlowed on our service for from 10 to 24 years. It appears t h a t no longer are the critics of the operation justified in their former skepticism regarding the long-term protection offered by the procedure. T h e 16 r e c u r r e n t ulcers resulted from a proved incomplete vagotomy in 9 cases (proved by insulin test and at reoperation), a Zollinger-Ellison turnor in 4 patients, a functioning a d r e n a l t u m o r in 1 case, and 2 patients possibly had an incomplete vagotomy. T h e last 2 patients bled massively from a r e c u r r e n t ulcer several m o n t h s following the original operation, and at emergency re-exploration a high resection of the gastric pouch was done. No a t t e m p t was m a d e to d e t e r m i n e the status of the vagal denervation due to, the patients' poor condition. Currently, both are doing well, Fro. 1 2 . - - U l c e r recurrence among 3,000 patients undergoing vagotomy-antrectomy.

IN 16 Patients ( 0 . 6 % )

Z.E. TUMOR 4 Potients

ADRENAL TUMOR I

Patient

PROVED INCOMPLETE VAGOTOMY - 9 Patients

22

I,

BILLROTH

6 i

I

II

BILLROTH Tr PROVED INCOMPLETE VAGOTOMY POSSIBLE INCOMPLETE VAGOTOMY

3 I

O

FUNCTION I NG ADRENAL TUMOR

I

2

Z.E. TUMOR

2

Fie,. l : l . - - T | l e B i l l r o t h I r e c o n s t r u c t i o n w i l h a s s o c i a t e d v a g o t o m y a p p e a r s to be a s e f f e c t i v e a s t h e B i l l r o t h I I m e t h o d in p r e v e n t i n g r e c u r r e n t u l c e r .

a n d a r e a c h l o r h y d r i c as t h e r e s u l t of t h e high resection. T h e s m a l l rem a i n i n g p a r i e t a l cell m a s s in each p a t i e n t r e n d e r s t h e r e s u l t s of t h e Holl a n d e r test invalid, a l t h o u g h t h e r e s p o n s e in both p a t i e n t s is n e g a t i v e (Fig. 12). F r o m a s u r v e y of the l i t e r a t u r e , a p p a r e n t l y m o s t r e c u r r e n c e s following t h e c o m b i n e d o p e r a t i o n a r e d u e e i t h e r to i a t r o g e n i c f a c t o r s or to endoc r i n e s e c r e t i n g t u m o r s . T h e c o n c e p t of t h e o p e r a t i o n as e x p l a i n e d by b o t h S m i t h w i c k a n d Ed{vards 25 y e a r s ago a p p e a r s even m o r e s o u n d today. D u r i n g o u r e a r l y e x p e r i e n c e , a B i l l r o t h II t y p e of r e c o n s t r u c t i o n was r o u t i n e l y e m p l o y e d following v a g o t o m y - a n t r e c t o m y , h u t l a t e in 1951 we s t a r t e d to utilize a B i l l r o t h I a n a s t o m o s i s . A:~: ~.xperience i n c r e a s e d with t h e l a t t e r m e t h o d , we g r a d u a l l y b e g a n u s i n g it on even t h e difficult u l c e r p r o b l e m s . I t is o u r r e c o n s t r u c t i o n of choice at p r e s e n t . O u r s t u d i e s show t h a t the B i l l r o t h I p r o c e d u r e is j u s t as effective in p r e v e n t i n g r e c u r r e n t u l c e r a t i o n as is t h e B i l l r o t h I I technic. T h e c o n t r a i n d i e a t i o n s to e m p l o y ing t h e B i l l r o t h I m e t h o d a r e s t e n o s i s e x t e n d i n g into t h e r e t r o b u l b a r duo d e n u m , p r o n o u n c e d i n f l a m m a t o w c h a n g e s in t h e o p e r a t i v e a r e a a n d m a r k e d obesity, w h i c h r e n d e r s e x p o s u r e i n a d e q u a t e . C u r r e n t l y we a r e u s i n g t h e B i l l r o t h I r e c o n s t r u c t i o n ( t e r m i n o - t e r m i n a l ) in m o r e t h a n 95% of cases (Fig. 13). P r a c t i c a l l y all o b s e r v e r s h a v e p e r f o r m e d t r u n c a l r a t h e r t h a n selective v a g o t o m y w h e n c a r r y i n g o u t t h e c o m b i n e d p r o c e d u r e . Griffith e l al. s'l exp r e s s e d a fleeting e n t h u s i a s m s e v e r a l y e a r s ago for t h e selective technic, bu~ tol]ow-up d a t a w e r e n o t p u b l i s h e d . E x c e p t for a r e c e n t r e p o r t by S a w y e r s a n d Scott2~5 u s i n g t h e selective t e c h n i c in a small g r o u p of pat i e n t s w i t h a s h o r t follow-up s t u d y , few, if a n y s u r g e o n s h a v e c o m b i n e d selective v a g o t o m y w i t h c o n s e r v a t i v e distal resection.

LESS FREQUENTLY EMPLOYED OPERATIONS T h e r e a r e s e v e r a l o p e r a t i v e p r o c e d u r e s c u r r e n t l y u s e d in s o m e c e n t e r s for d u o d e n a l u l c e r w h i c h have n o t received wide a c c e p t a n c e b u t w h i c h 23

m a y be of some value in properly selected cases. T h e y are s u p r a - a n t r a l segmental resection, antro-distal duodenostomy, proximal duodenectomy with distal antrectomy, and simple gastroenferostomy. SUPRA-ANTRAL SEGMENTAL

RESECTION

In 1952, Wangensteen2.t7 repopularized segmental gastrectomy, which actually was an operative procedure probably first devised by Billroth but employed by MikuliczlT~ in 1897. Mikulicz and other G e r m a n surgeons soon al)andoned the procedure because of e m p t y i n g problems and anastomotic constrictions. T h e original operation consisted of resection of approximately 20-30% of the gastric corpus with gastroanterostomy. "~Vangensteen reasoned that such an operation, which avoided a surgical attack on the a n t r u m and diseased duodenal bulb, if effective for control of ulcer disease, would be a decided i m p r o v e m e n t over the Billroth II method. Obviously, however, from the s t a r t it was realized t h a t the operation had certain limitations in t h a t it could not be used in cases of obstruction and only in selected cases of perforation and bleeding. E x p e r i m e n t a l studies on dogs showed t h a t a 50°~" segmental resection followed by histamine in beeswax a d m i n i s t r a t i o n resulted in a 12% incidence of stomal ulcer. However, if the same animals were then subjected to antral resection, followed by histamine administration, the incidence of stomal ulceration rose to 88%. This gave strong support to the concept that the a n t r u m in continuity with an acid e n v i r o n m e n t does not potentiate ulcer disease. Indeed, with ~m a d e q u a t e proximal segmental resection, it was believed that the small retained acid fundic pouch would inhibit the release of antral gastrin.2:~e W h e n segmental gastrectomy was done on both the experimental animal and the h u m a n , W a n g e n s t e e n found that stasis occurred unless pyloroplasty or pylorotomy was added (Fig. 14). Bisecting the stomach largely vagotomized the distal segment, a fact obviously not appreciated by the early G e r m a n surgeons. W h e n W a n g e n s t e e n performed a 75 ~% segmental resection, the incidence of stomal ulcer over a several y e a r follow-up was only 2% but the incidence of significant postgastrect<)my sequelae was astonishingly high. W h e n estimated 40-50% segmental resections were In an effort to done, the incidence of stomal ulceration rose to 9-10,o. o7 reduce the rate of stoma] ulcer, both W a n g e n s t e e n and BernelS added

FzG. 14.--Supra-antral ~egmental gastrectomy with l;yloropla.~ty as performed i)y ~,Vangensteen.

24

truncal vagotomy to denervate the fundic pouch, but the incidence of ulcer recurrence was not reduced. Most of the recurrent ulcers appeared in the antral, segment near the lesser curvature. Ferguson56, 57 preserved the antral and pyloric vagal branches when performing vagotomy and s u p r a - a n t r a l gastrectomy in hopes of avoiding pyloroplasty, but the results were unsatisfactory. It would a p p e a r t h a t with the type of segmental gastrectomy as practiced by \Vangensteen, the extent of the proximal resection is of ~atmost importance in preventing stomal ulceration, and the role of antral inhibition is of lesser concern. Currently, Wangensteen uses segmental gastrectomy only in certain selected circumstances.2,15. 246, 248 \Voodward260 has shown in Pavlov pouch dogs that when most of the a n t r u m is removed the stimulating effect of food on pouch secretion is m a r k e d l y diminished. Segmental resection, which encompasses most of the a n t r u m and which retains more of the corpus as advocated by both Zoche 262 and Maki,J~4 m a y be more effective in reducing gastric acidity than the operation performed by Wangensteen. This latter modification combined with vagotomy will be d i s c u s s e d later u n d e r N e w e r Surgical Procedures. ANTRO-DISTAL DUODENOSTOMY In 1955, Poth~96 advocated a simple operative procedure, a modification of one previously described by both \Vilkie25~ and 1Rienhoff.206 in which the posterior wall oi the prepyloric a n t r u m is anastomosed to the fourth portion of the duodenum at the level of the ligament of Treitz. This procedure, being a ~onablative one, takes into consideration the preservation of inhibitory mechanisms that control gastric secretion, which is in marked contrast to most operations for ulcer, which are directed toward ablation of the mechanisms that excite acid pepsin secretion. PothZ02a had shown experimentally that irrigation of an excluded duodenojejunal loop with acid inhibited secretion in a histamine-stimulated innervated gastric pouch. With antroduodenostomy, he believed t h a t the acid chyme delivered through the prepyloric shunt on being exposed to a large area of duoden"l mucosa would excite the release of duodenal inhibitory hormones, n a m e l y cholecystokinin, enterogastrone, secretin and serotonin, all potent inhibitors of gastric acid secretion. P o t h believed that complementary vagotomy was contraindicated, as Code and Watkinson32 had shown t h a t the maximal inhibitory effects of duodenal hormones are dependent on p a r a s y m p a t h e t i c innervation. As an alternative procedure for patients undergoing operation for hemorrhage, Poth resected the distal pylorus and duodenal bulb, closed the duodenal s t u m p and anastomosed the end of the stomach to the side of the distal duodenum. Thus, the proximal portion of the d u o d e n u m was excluded in the latter operation and was selectively excluded in, the former. T h e fourth partion of the duodenum was chosen to admit the gastric chyme, as P o t h b e l i e v e d ' t h a t this area provided for the m a x i m a l release of duodenal inhibitory hormones. T h e two procedures were not regarded as a solution to the surgical t r e a t m e n t of ulcer, but it was thought that they might prove effective in most instances. Both procedures" indeed subjected the patient to minimal hazards, and each would 25

not interfere with any additional gastric operation should one prove necessary in the future.199 In 43 patients followed up to 10 years the results were very satisfactory. No stoma] ulcers took place, and additional gastric operations were not necessary.~gs Poth~-97 states t h a t he now has used the procedure in 80 patients, and the results continue to be satisfactory. Two patients have been re-explored for hemorrhage, but no stomal ulcer was found and bleeding was due to a suture granuloma in each case.

PROXIMAL DUODENECTOMY-DISTAL PYLORECTOMY In 1965, M a c F e e and Sax 16l reported 116 patienis undergoing a very limited resection of the distal pylorus and proximal duodenum with closure of the duodenal s t u m p and anastomosis of the distal stomach to the side of the d u o d e n u m beyond the a m p u l l a of Vater. T h e longest follow-up was 7 years, and 88.61~b of patients experienced satisfactory results. Eleven per cent of patients developed new uicer-like symptoms, but recurrent ulcers were proved in only 5 patients. In most of the cases, a decline in free hydrochloric acid was observed following operation, but appreciable free acid was still present. T h e physiologic concept behind this operative procedure is somewhat similar to the operation described by Poth. Poth believes, however, t h a t superior clinical results and more adequate lowering of gastric acidity can be obtained by uti!izing the most distal portion of the duodenum.

SIMPLE GASTROENTEROSTOMY Gastroenterostomy, fortunately, has now been entirely abandoned for the t r e a t m e n t of duodenal ulcer in the average-risk patient, but still Fro. 1 5 . - - A , antro-distal d u o d e n o s t o m y , B, distal p y l o r e c t o m y with antro-distal duodenostomy. C, modification of B as advocated by MaeFee, and D, s i m p l e gastroenteroslomy.

•

26

li

should be given strong consideration in the elderly high-risk individual in whom ulcer complications d e m a n d surgical intervention. In elderly highrisk patients who have not bled, and particularly in elderly patients with gastric outlet obstruction, gastroenterostomy alone usually is a satisfactory operation. T h e addition of vagotomy in the latter circumstance is contraindicated, as resultant vagotomy atony will produce a further delay in e m p t y i n g (Fig. 15).

NEWER SURGICAL PROCEDURES T h e r e are several new surgical procedures for control of duodenal ulcer that currently are being evaluated by both experimental and clinical investigators in cer','dn surgical centers. T h e early results with some of these operations h:tve ln'oved exciting, but for lhe most part they must be considered still in the experimental stages and are by no means recommended for widespread adoption. I have had no personal experience with any of these procedures, but as the result of frequent communications invoh, ing those pioneering these new operations, each will be described and the earl,,, rest, Its will be cited. REVERSAL OF THE ~ODENUM

Within recent years, Poth~S, 200-202 has suggested reversal of the flow of gastric chyme through the entire length of the d u o d e n u m as a method of surgical t r e a t m e n t for duodenal ulcer. T h e operation Ls based on the concept of the inhibitory effect on gastric secretion produced by bathing the duodenal mucosa with acid gastric chyme. N o r m a l l y onIy the small segment of duoden~im above the level of the entrance of the pancreatic ducts is rendered sufficiently acid by the gastric chyme, and according to Poth duodenal reversal excites a pronounced outpouring of duodenal inhibitory hormones. T h e operative procedure is quite simple. It consists of a minimal resection of the distal pylorus and duodenal bulb. T h e duodenum is next transected as close to the ligament of Treitz as possible. T h e duodeno jejunal junction is then anastomosed end-to-end to the distal portion of the stomach, and the distal divided end of the j e j u n u m is anastomosed to the duodenal bulb. Thus, a physiologic and anatomic reversal of the d u o d e n u m is produced (Fig. 16). Delivering the flow of gastric chyme initially into the distal duodenum, Poth believes, provides for maximal liberation of gastric antisecretagogues. Should the gastric t h y m e be delivered into the d u o d e n u m by a more proximally constructed shunt, close to the a m p u l l a of Vater, the inhibitory hormonal effects on gastric secretion would be diminished. A gastroduodenal shunt constructed at this latter level would provide for excess secretin release of pancreatic bicarbonate. a strong neutralizer of acid gastric t h y m e ; in addition, the role of secretin as a potent inhibitor of a n t r a l gastrin would be diminished. It is well recognized t h a t the proximal duodenum, through hormonal inhibitory mechanisms, is able to suppress gastric secretion. However, by physielogica!ly reversing the duodenum, P o t h contends that an even more powerful brake is applied to inhibit gastric secretory activity: As a result of duodenal r.eversal there occurs an increase in exposure of the duodenal mucosa to the acid gastric chyme brought about by increased e m p t y i n g time of the reversal due to bidirectional peristalsis i n the segment. Thus, 27

FI6. 1 6 . ~ A , .,~hysiologic reversal of the entire duodenum. B, the identical procedure as A but with the gastric antrum removed.

acidification of the d u o d e n u m is continuous a n d t h e r e is little or no neut r a ! i z a t i o n of the gastric contents d u r i n g its route t h r o u g h the d u o d e n u m . P o t h s t a t e s t h a t by such a p r o c e d u r e the gastric a n t i s e c r e t a g o g u e activity is a u g m e n t e d by a p p r o x i m a t e l y 400 .,~o. P r i o r to a p p l y i n g the p r i n c i p l e of d u o d e n a l reversal to patients. P o t h p e r f o r m e d several ingen!ous e x p e r i m e n t a l p r o c e d u r e s to test the effectiveness of distal d u o d e n a l iilhibition on gastric secretion a n d u l c e r formation. U s i n g the H e n l e y - S i l b e r l n a n n 2'-'4 p r e p a r a t i o n , which consists of interposing a 20-cm, .;soperistaltic s e g m e n t ef ileum between the divided end of the distal s t o m a c h a n d d u o d e n a l bulb, P o t h found t h a t 93% of a n i m a l s developed an ileal pouch ulcer in the proximal p o r t i o n of the ileal segm e n t . In contrast, w h e n the ileal s e g m e n t was i n t e r p o s e d between the end of the s t o m a c h and the f o u r t h portion of the d u o d e n u m a n d the duodenal s t u m p closed, only 30% of the alfimals developed a pouch ulcer (Fig. 17). I n the r e m a i n i n g 70% of a n i m a l s without pouch ulceration, the ileal transfer was t h e n d e t a c h e d f r o m the fourth portion of t h e d u o d e n u m and anast o m o s e d to--the reopened d u o d e n a l s t u m p . T h i s resulted in a high incidence of ileal s e g m e n t ulcer. I n a n o t h e r g r o u p of e x p e r i m e n t s , P o t h interpolated an isoperistaltic ileal s e g m e n t between the distal stomach and d u o d e n u m at the level of T r e i t z ' s ligament. T h e j e j u n u m was t h e n divided just beyond the i l e o d u o d e n o s t o m y a n d the proximal cut end of the bowel was closed. T h e distal divided end of the j e j u n u m was a n a s t o m o s e d to the proximal d u o d e n u m . In the presence of total d u o d e n a l reversal, no a n i m a l developed u l c e r a t i o n in t h e i n t e r p o s e d ileal s e g m e n t (Fig. 18). P o t h found that with the H e n l e y - S i l b e r m a n n p r e p a r a t i o n , H e i d e n h a i n poi~ches secreted three times as m u c h acid when the gastric c h y m e traversed its n o r m a l course t h r o u g h the d u o d e n a l sweep as c o m p a r e d to 28

A

Fit;. 1 7 . ~ A , the Henfey-Silbermann ileal conduit is a uniformly uleerogenic preparation. B, shunting the ileal segment into the distal ducxtenum provided prolection against ileal ulceration in three-fourths of the extrerimental animals. (Courtesy of E. g, Poth.)

p r e p a r a t i o n s in which the gastric c h y m e flowed t h r o u g h a complete duodenal reversal. H i l b u n et al3O.J d e m o n s t r a t e d 70% protection against pouch ulceration when a n interposed small bowel s e g m e n t was placed between the distal s t o m a c h and proximal d u o d e n u m but with a n t r e c t o m y and a n t e r i o r vagoto m y added. T h e s e results were c o m p a r a b l e to those of P o t h in which the d u o d e n u m was reversed, but with a n t r a l tissue a n d vagal function preserved. HammerS9 has produced ulceration by reversing the d u o d e n u m , but in his e x p e r i m e n t s a short s e g m e n t of proximal j e j u n u m also was included in the reversal. In cases in which he reversed the d u o d e n u m alone, no ulcerations developed. P o t h believes t h a t the physio|ogic concept of duodenal reversal is sound, but he readily a d m i t s c u r r e n t knowledge of t h e complex m u l t i p l e a n t i s e c r e t a g o g u e m e c h a n i s m s of the d u o d e n u m is f r a g m e n t a r y . H e also postulates that the d u o d e n u m m a y play a dual role in r e g u l a t i n g gastric secretory activity. F o r example, in the M a n n - W i l l i a m s o n p r e p a r a t i o n , the Fit;,. 18.--Modifying the Henley-Silbermann preparation by shunting the ileal segment into the distal duodenum combined with duodenal reversal protects against ileal, gastric and duodenal ulceration in the experimental animal. (Courtesy of E. J. Poth.)

DU

29

S h a y rat, and patients with pyloric o b s t r u c t i o n - - a l l conditions in which acid gastric reflux does not enter the duodenum, there results a m a r k e d rise in gastric secretions. Thins secretory rise m a y possibly be due to alkalinization of the d u o d e n u m with release of a strong gastric secretagogue. Evidence to substantiate this postulate was brought out in one of Poth's patients who u n d e r w e n t duodenal reversal and subsequently developed early stornal obstruction. T h e r e occurred a m a r k e d rise in gastric acid secretions, but on correction of the obstruction with passage of gastric c h y m e i n t o the reversed d u o d e n u m , gastric secretions fell a b r u p t l y and the free hydrochloric acid value was zero. Poth197 states t h a t during the past 3 y e a r s he has reversed the duoden u m in 9 patients. E i g h t of the 9 c u r r e n t l y are doing satisfactorily and the fasting intragastric p H varies from 5.0 to 7.5. One patient, however. developed a stomal ulcer at the gastro-distal-duodenal anastomosis. Currently, P o t h advises removing the gastric a n t r u m at the time of duodenal reversal but does not advocate vagotomy. H e believes the latter procedure to be strongly contraindicated as vagal denervation diminishes the duodenal inhibitory influence on gastric secretion. Figure 19 shows a postoperaFIc,. 19.--Postot~erative b a r i u m s t u d y follo~ving a n t r e c t o m y with duodenal reversal. N o t e that the stomach is not dilated and the duodenal contour is normal. ICourtesy of E. d. Poth.

30

tive gastrointestinal contrast sf:udy of a patient who has undergone duodenal reversal. D u o d e n a l reversal possibly m a y have merit as an operation to control ulcer disease, but it is m y opinion that this procedure currently should be performed only by such investigators as Poth and his group. Additional case m a t e r i a l with careful long-range follow-up is essential to determine w h e t h e r the procedure later m a y be recommended for more general use. MUCOSAL ANTRECTOMY WITH: VAGOTOMY I n 1963, Kirk139 of London devised an operation for benign gastric ulcer in which he stripped the mucosa from the gastric a n t r u m and left the musculoserous wall intact. In 1965,1,*0 he combined excision of the antra] mucosa with either total or selective vagotomy for the elective t r e a t m e n t of duodenal ulcer. T h e operation was equivalent to a Billroth I gastrectomy but possessed /be attractive advantage of obviating a dissection and division of the diseased duodenum. It did, however, destroy pyloric function. and obviously was not always applicable to large penetrating ulcer craters with marked duodenal bulb distortion and stenosis. E a r l y postoperative secretory studies indicated an absence of free hydrochloric acid on insulin stimulation, low basal acid secretions and m a r k e d decline in response to histamine, the latter declining from an average of 20 m E q . / h r . preoperatively to 2 m E q . / h r , postoperatively. To ensure complete removal of the antraI mucosa, K i r k administered intravenous gastrin Rentapeptide at the beginning of the operative procedure to induce pa,'ietal cell activity. Congo red, which stains the a n t r u m red and the parie-tal cell mass black, was then introduced through a nasogastric tube. The proximal d u o d e n u m and distal one-half of the anterior gastric wall were then opened widely to expose the antral mucosa. As an alternative method to define the antral extent, blue litmus p a p e r could be applied to the gastric mucosa. T h e antral submucosa was next injected with adrenalin-saline solution, and the entire antral mucosa was stripped from the underlying submucosa. The dissection was begun proximally and encompassed the entire circumference of the a n t r a l segment. T h e distal extent of the dissection extended to the duodenal mucosa. T h e submucosal bleeding points were controlled with fine ligatures, but more recently K i r k has employed electrocoagulation with no u n t o w a r d effects. Following removal of the entire a n t r a l mucosa, the mucosa and muscularis of the distal gastric corpus were sutured to the mucosa muscularis of the duo d e n u m with a continuous siJture of catgut. T h e anterior wall duodenal incision was lengthened if necessary to accommodate the full width of the gastric corpus. An anterior seromuscular l a y e r of i n t e r r u p t e d silk completed the anastomosis. T h e resultant gastroduodenostomy in essence created a Mikulicz-type pyloroplasty (Fig. 20). T h e large circumferential seromuscular collar that resulted from the antral mucosal d e n u d a t i o n was then brought anteriorly toward the midline and sutured over the gastroduodenal anastomosis. N o excessive bleeding resulted from the procedure and no obstructive p h e n o m e n o n took place. Postoperative barium studies revealed some decrease in the size of the stomach, and the gastroduodenal channel was widened (Fig. 21). Gastroscopic studies revealed essentially normal findings. 31

fl :

"

FIG 2 0 . - - A and B, the Kirk operation. T h e antral mucosa has been defined with Congo red and will be stripped from the underlying mucosa. C and D, the antral mucosa has been removed and the mucomuscularis of the corpus is being sutured to the mucomuscularis of the proximal duodenum. E . /he reconstruction has been completed and the large seromuscular collar has been sutured anteriorly over the gastroduodenal anastomosis. (Courtesy of R. M. Kirk.

D u r i n g a recent visit to our institution, K i r k stated -~hat he has now performed the operation on 112 patients with d u o d e n a l ulcer. T h e r e have been no deaths directly a t t r i b u t a b l e to the o p e r a t i o n a n d complications have been rare. N o p a t i e n t has developed a recurren t ulcer. T h e longest follow-up has been more t h a n 7 years. Bilious regurgitation was experienced by 5 patients, and several patients noted mild ~to m o d e r a t e sympt o m s of the d u m p i n g syndrome. Gastric secretory studies continue to produce low acid values. C u r r e n t l y , Kirk~3S. 14I, 142 m a i n t a i n s his original enthusiasm for the operation and prefers selective vagotomy to other metllods of vagal denervation. During the past 3 years. Grassi73 of R o m e has expressed both an ex-

32

Fig. 2 1 . - - A , gastrointestinal contrast study after the Kirk procedure depicting th6 gastroduodenal anastomosis. B, r, ote widening of the gastropyloric canal and decrease in tile size of the stomach. ~Courtesy of R M. Kirk.,

33

p e r i m e n t a l a n d a clinical interest in several new operations for duodenal ulcer, including mucosal a n t r e e t o m y with selective vagotomy. H e states 7~ t h a t he has p e r f o r m e d the l a t t e r o p e r a t i o n in 78 eases, a n d over a s h o r t follow-up period the r e s u l t s have been satisfactory in 97%. P o s t o p e r a t i v e gastric secretory studies, including m a x i m u m h i s t a m i n e stimulation, have shown e x t r e m e l y low values. ]Recently, Grassi has combined proximal selective v a g o t o m y with mucosal a n t r e c t o m y , t h e r e b y m a i n t a i n i n g distal a n t r a l vagal innervation, which theoretically should provide for fewer dist u r b a n c e s in gastric e m p t y i n g . Truini242 has also recently reported satisfactory results with the Kirk-Grassi operation. To m y knowledge, clinical interest in mucosal a n t r e c t o m y has been expressed by only a few investigators. E x c e p t for Griffith, no one in the U n i t e d S t a t e s has carried out the procedure. A f t e r s p e n d i n g some time with Kirk, Griffith p e r f o r m e d the p r o c e d u r e in several p a t i e n t s and was i m p r e s s e d by its ineffectiveness in p r e v e n t i n g s y m p t o m s of the d u m p i n g s y n d r o m e . As with an), new operative procedure, it obviously is not possible at this time to j u d g e w h e t h e r mucosal a n t r e e t o m y with selective v a g o t o m y will prove effective as a m e t h o d of t r e a t m e n t of ulcer disease. T h e p r o c e d u r e does have the a t t r a c t i v e features of technical simplicity, p r e s e r v a t i o n of gastric tissue and m a i n t e n a n c e of g a s t r o d u o d e n a l continuity. SU-PRA:PYLORIC ANTRECTOMY WITH VAGOTOMY Most of the early clinical experiences with s u p r a p y l o r i c s e g m e n t a l gast r e c t o m y resulted in failure because too large a s e g m e n t of distal a n t r u m was left b e h i n d a n d the a m o u n t of gastric corpus removed was insufficient. In the early 1960s. F l y n n a n d LongmireSS a n d Killen and Symbas1,~- perf o r m e d 5 0 - 7 5 % s e g m e n t a l resections in the e x p e r i m e n t a l animal, preserving the distal 2 cm. of the a n t r u m . T h e r e m a i n i n g a n t r a l m u c o s a was removed, after which the m u c o s a of the c o r p u s was a n a s t o m o s e d to the d u o d e n a l m u c o s a a n d the s e r o m u s c u l a r coats t h e n a p p r o x i m a t e d . T h e a u t h o r s r e p o r t e d r h y t h m i c e m p t y i n g of the gastric contents and observed i n t r a l u m i n a l pressure changes in the pyloric area. Because of technical difficulties a n d a h,:gh m o r t a l i t y rate in the e x p e r i m e n t a l p r e p a r a t i o n , the p r o c e d u r e failed to gain clinical acceptance. T h e s e investigators also expressed the belief t h a t with a badly s c a r r e d or stenotic d u o d e n u m , a n t r a l s t r i p p i n g would be technically impossible. Thereforel such a sphincterp r e s e r v i n g g a s t r e c t o m y would indeed have limitations. I n 1967, M a k i e t a1.',64 described a modified s e g m e n t a l resection t h a t consisted of a s u p r a p y l o r i c a n t r e c t o m y . M a k i p e r f o r m e d the o p e r a t i o n for a distally located gastric ulcer and t e r m e d the p r o c e d u r e a pyloricpreserving gastrectomy. T h e concept behind t h e o p e r a t i o n was to preserve the distal 1.5-2 cm. of a n t r u m and pylorus, t h e r e b y obviating ~the need for a d r a i n a g e procedure. It was h o p e d t h a t such a n o p e r a t i o n would e l i m i n a t e s y m p t o m s of the d u m p i n g s y n d r o m e . Prio r e x p e r i m e n t a l work by Sugawara23~ using e l e c t r o m y o g r a p h y d e m o n s t r a t e d the various motility c h a n g e s t h a t occur in the s t o m a c h w h e n it is bi~;ected a n d reanastomosed at various levels. H e found t h a t f~::qnent counterperistalsis took place in the portion of s t o m a c h distal to t h e r e a n a s t o m o s i s when the org a n was bisected at the a n t r o c o r p a l junction, However, no such counter34

contractions occurred whel~ the stomach was bisected and reanastolnosed 1.5-2 cm. proximal to the pyloric ring. W i t h the more proximal bisections, vigorous contractions and anti peristaltic rustles were associated with gastric stasis and delayed emptying. Kuroda150 found t h a t the addition of bilateral truncal v a g o t o m y to gastric bisection did not appreciably enhance the spastic contractions or antiperistalsis in the gastric s e g m e n t distal to tile site of division. In other experiments, simple gastric bisection a n d reanastomosis was done at various levels with s t u d y of i n t r a l u m i n a ] p r e s s u r e changes and e l e c t r o m y o g r a p h y . M a k i found t h a t transection 4 cm. proximal to the pyloric ring resulted in increased m o t o r activity with elevated i n t r a l u m i n a l pressure, p o s s ; b l v indicative of delayed emptying. T r a n s e c t i o n with reanastomosis 2 cm. proximal to the pylorus showed changes c o m p a r a b l e to the controls. Division of the a n t r u m 1 cm. or less from the pyloric ring lowered the m e a n i n t r a l u m i n a l pressure, indicating loss of sphincter-it action of the pylorus. Thus, M a k i believed t h a t in the pyloric-preserving procedure, division o f the a n t r u m 1.5-2 cm. from the pyloric ring was critical a n d absolutely vital to preserve pyloric function. W h e n applied clinically, the gastric e m p t y i n g time of most postoperative p a t i e n t s was similar to those patients who had never u n d e r g o n e a gastric operation. Also, it was t h o u g h t unlikely t h a t the small segment, of retained a n t r u m would predispose to r e c u r r e n t ulceration, since it was left in continuity with an acid fundic e n v i r o n m e n t . Currently, Maki has e m p l o y e d the o p e r a t i o n for gastric ulcer in 79 cases, and the results thus far have been excellent. No p a t i e n t experiences s y m p t o m s of the d u m p i n g syv.drome and no p a t i e n t has developed a r e c u r r e n t ulcer. T h e operative m o r t a l i t y rate has been zero. Initially, M a k i employed pylorus-preserving g a s t r e c t o m y only for the t r e a t m e n t of benign gastric ulcer and other benign lesions of the distal stomach. At ~he suggestion of Griffith in 1969, he began to use the operation in selected cases of duodenal ulcer but with the addition of e i t h e r selective or truncal vagotomy. Over a short follow-up period in a small 1lumber of cases, the results indeed have been encouraging. T h e gastric e m p t y i n g time of the p a t i e n t s subjected to pylorus-preserving g a s t r e c t o m y with vagotomy averages slightly less t h a n the controls, but is m o r e delayed when c o m p a r e d to patients who have u n d e r g o n e v a g o t o m y - a n t r e c t o m y with a classic Billroth I reconstruction. No s y m p t o m s of the d u m p ing s y n d r o m e have occurred, and chemical balance studies of fecal fat a n d p r o t e i n yield results s u p e r i o r to those obtained with the classic Billroth l: reconstruction. Gastric anal~:sis shows t h a t with the a u g m e n t e d h i s t a m i n e test, p r e o p e r a t i v e values as high as 95 m E q . / L , have been reduced to 18 m E q . / L , or less following operation. P o s t o p e r a t i v e H o l l a n d e r tests have been negative.163 Goodale et ai..66 in r e c e n t e x p e r i m e n t a l studies, showed that t h e Maki p r o c e d u r e w i t h o u t c o m p l e m e n t a r y vagotomy resulted in a 56~, decrease in free acid o u t p u t from H e i d e n h a i n pouches. Of e x t r e m e interest was t h a t the o p e r a t i o n gave 100% protection against neostomal ulceration when the H e n l e y - S i l b e r m a n n p r e p a r a t i o n was added. H e a l s o s h o w e d that p y l o r u s - p r e s e r v i n g g a s t r e c t o m y h a d distinct n u t r i t i o n a l a d v a n t a g e s over t h e I~illroth I and Billroth I I types of resections. Goodale concluded that the Mak] procedure, by v i r t u e of its substantial reduction in acid o u t p u t , w"

35

its preservation of normal emptying, its ease of e x e c u t i o n and its nutritional value, should be given a trial in the t r e a t m e n t of selected patients with a nonobstructing duodenal ulcer. A m d r u p and Gri.ffith2 p e r f o r m e d pre- and postoperative gastric motility and secretory studies ill H e i d e n h a i n pouch dogs undergoing suprapyloric a n t r e c t o m y with selective vagotomy of the parietal cell mass. Two groups of animals were studied and only the distal 2 cm. of a n t r u m was retained in each. One group, however, was subjected to suprapyloric a n t r e c t o m y ( M a k i procedure) whereas the other group u n d e r w e n t suprapyloric mucosal a n t r e c t o m y (modified K i r k operation). No gastric stasis took place in either group and m u c h of the normal r h y t h m i c e m p t y i n g of the stomach was preserved in both• Gastric motility was, however, less altered by s u p r a p y l o r i c mucosal a n t r e c t o m y than by s u p r a p y l o r i c antral resection. In both groups, with only 2 cm. of distaI antral tissue remaining, Heidenhain pouch secretions/fell markedly. It was believed that gastric vagal innervation of the distal 2 era. antral segment was indeed insignificant or p e r h a p s destroyed by suprapyloric resection with selective vagotomy of the parietal cell mass in contrast to its preservation when suprapyloric mucosal a n t r e c t o m y was performed. This probably accounted for less motility disturbance following the latter operative modification. Nevertheless, both A m d r u p and Griffith reasoned that preservation of distal a n t r a l innervation was of no great importance when evaluating the results of the ~wo groups. In addition, suprapyloric mucosal a n t r e c t o m y was a more dl.fficult and time-consuming operation. This brought up the all-important que.~tion as to w h e t h e r suprapyloric a n t r e c t o m y i n combination with selective (gastric) vagotomy or truncal vagotomy, procedures much easier to execute a n d which purposely denervate the small retained a n t r a l segment. would prove effective in preventing stasis and in controlling symptoms of the d u m p i n g syndrome. E v e r e t t and Griffith46 ~ecently accumulated d a t a which showed t h a t selective (gastric) vagotomy (not parietal cell vagotomy) in combination with s u p r a p y l o r i c a n t r e c t o m y produces little motility change and ~:~s quite effective in lowering gastric secretions and in preventing stasis. Thus. vagal preservation to the small antral segm e n t as achieved with parietal cell vagotomy is of little or no importance. T r u n c a l vagotomy in combination w i t h suprapyloric a n t r e c t o m y has, however, resulted in gasiric stasis.l:~6 Following extensive experimeiltal investigations, Griffith and KilbyS0, 135 have now employed st:prapyloric a n t r e c t o m y plus selective (gastric) vagotomy in carefully selected cases of nonobstructing duodenal ulcer. T h e y m a r k the prc.~imal line of transection at the proximal extent of the ant r u m as d e t e r m i n e d by an intragastric s p r a y of Congo red, and the distal line of transection is m e a s u r e d 1.5 era. proximal to the pyloric ring. T w e n t y - s i x patients have now - n d e r g o n e the procedure and none has syml)toms of the d u m p i n g s y n d r o m e even when challenged with a d u m p i n g . p r o v o k i n g meal. A m o n g these patients, 19 show a m a r k e d decrease in basal acid secretion with no clinical or roentgen evidence of gastric stasis (Fig. 22). Seven patients a m o n g the group of 26 developed postoperative s y m p t o m s of gastric stasis of mild to m o d e r a t e degree. However, in no patient has stasis been severe enough to w a r r a n t additional ol~era{iou. T h r e e of the patients d e m o n s t r a t e d no stasis on x-ray .~lu(ly. but the remaining ,1 showed roentgen evidence of stasis with delay 36

Fro. 2 2 . ~ P r e - and postoperative gastrointestinal s t u d i ~ showing absence of both stasis and gastric dilatation following selective vagotomy and suprapyloric antrectomy. (Courtesy of C. A. Griflith.)

in e m p t y i n g up to 6 hours. T h e barium mixture a p p e a r e d to hesitate at the I)ylorus. and the deformed d u o d e n u m and the antrocorpal anastomosis did not a p p e a r to contribute to the delay. Griffith has been unable to explain the reason for stasis occurring in apl)roximately one-fourth of the patients, but believe.4 it possibly could be related to tile amount of stomach removed. H e l)ogtulated that the proximal extent of the a n t r u m could not be correlated with the motile function of the distal stomach. Therefore, he currently removes slightly more of the gastric corpus, whmh amounts to approxinmtety a 50°~) resection. As an additional m e a s u r e to prevent stasis, GriffithS0 recently informed me that he is now adding a short pylorotomy to the operative procedure. In other words, following suprapylorie a n t r e c t o m y and selective (gastric) vagotomy, he performs a full-thickness longitudinal transection on the anterior surface of tile t)3"loric ring. T h e incision averages apl)roximately 3 ram. in length and extends through the mueosa. T h e pylorotomy incision is then closed transversely with two to three fine interrupted silk sutures. Grittith t e r m s this addition a "mini Heineke-Mikuliez pyloroi)lasty" (Fig. 23). It does preserve.pyloric function to some extent and in 15 additional patients ol)erated on to date no evidence of stasis either clinically or on roentgen study has occurred and d u m p i n g s y m p t o m s cannot be induced. Griffith prefers to continue eml)loying selective (gastric) vagotomy with the supral)yloric resection and sees no advantage in utilizing selective vagotomy of tile parietal cell mass. In addition to dividing the gastrib vagi with the selective technic, no a t t e m p t is m a d e to l)reserve the pyloric nerve twig from the hepatic vagal branch to the preserved distal a n t r u m . Both Griflith and Maki believe that this small nerve is of little consequence, for on electrical stimulation it does not produce pyloric contractions or elicit release of gastrin. T r u n c a l vagotomy in combination with sut)r~lpyloric resection, however, I)robably is contraindicated, for in the expert37

FIc. 23.---Selective vagotomy with suprapyloric antrectomy and a mini-pyloroplasty.

m e n t a l a n i m a l it produces a m a r k e d i.ncrease in H e i d e n h a i n pouch secretions, even in the presence of the S m a l l r e t a i n e d distal a n t r u m . T h i s observation is in accord with the postulate of H a r t , t h a t in some u n k n o w n way p r e s e r v a t i o n of t h e i n t a c t celiac a n d h e p a t i c vagal b r a n c h e s (as achieved with selective v a g o t o m y ) inhibits gastrin release. A l t h o u g h the results have been e n c o u r a g i n g in the m a j o r i t y of the patients o p e r a t e d on by both M a k i a n d Griffith. the p r o c e d u r e should not be a c c e p t e d for general use for d u o d e n a l ulcer until t h e a f o r e m e n t i o n e d investigators h a v e p r e s e n t e d additional data, including longer follow-up studies. SELEC'~J[VE VAGOTOMY W I T H O U T D R A I N A G E

According to Griffith,Sg W e r t h e i m e r of F r a n c e in 1922 was the first to p e r f o r m selective v a g o t o m y alone in both the e x p e r i m e n t a l a n i m a l a n d m a n . T h e o p e r a t i o n w a s done largely for tabetic crisis and functional disorders of the g a s t r o i n t e s t i n a l tract. A p p a r e n t l y little recognition was subs e q u e n t l y given selective v a g o t o m y w i t h o u t d r a i n a g e until Jackson'13 of A n n A r b o r in 1948 a n d Franksson60 of S w e d e n in 1948 expressed renewed e n t h u s i a s m for the p r o c e d u r e in the t r e a t m e n t of d u o d e n a l ulcer: this ent h u s i a s m proved to be short:lived. T h e i r work followed the early publication by D r a g s t e d t w h e n bilateral t r u n c a l v a g o t o m y alone was being used for the t r e a t m e n t of d u o d e n a l ulcer. J a c k s o n advocated a n t e r i o r - t o t a l and posterior-selective vag.gtomy, w h e r e a s F r a n k s s o n perfo .treed bilateral selective denervation. T h e results obtained by these two clinical investigators proved disappointing, as did those of D r a g s t e d t , for all t h r e e realized the need for gastric d r a i n a g e when a p p l y i n g e i t h e r truncal or selective vagal i n t e r r u p t i o n . D r a g s t e d t voiced s t r o n g criticism of the selective technic a n d as a result t h e p r o c e d u r e fell by the wayside. N o f u r t h e r m e n t i o n was m a d e of selective vagotorny until Griffith a n d Harkins81 published an exp e r i m e n t a l r e p o r t in 1957, a n d in the early 1960s B u r g e 2s. 29 of L o n d o n began a p p l y i n g the selective technic on a clinical basislbut always in combination with a gastric d r a i n a g e procedure. Initially, B u r g e p e r f o r m e d a n t e r i o r selective a n d posterior t r u n c a l vagotorny, but l a t e r a d o p t e d the bilateral selective technic. By the mid-1960s, after a n extensive clinical experience, B u r g e h a d become dissatisfied with the c o m b i n a t i o n of selective vagotomy a n d p y l o r o p l a s t y due to the large n u m b e r of p a t i e n t s presenting significant d u m p i n g s y m p t o m s . H e s t a t e d t h a t it would indeed be 38

an i m p o r t a n t step forward in ulcer surgery if one could eliminate symptoms of the d u m p i n g s y n d r o m e through preservation of the pyloric sphincter mechanism. Burge reasoned that by preserving the pyloric branches of the hepatic plexus in selective vagotomy, the normal function of the pylorie canal possibly might be preserved, and thus vasomotor phenomena, bilious regurgitation and d i a r r h e a associated with d u m p i n g prevented. Also, by sparing the celiac branch of the right vagus, troublesome post-truneal vagotomy d i a r r h e a might be avoided also. Burge readily admitted, however, that the fune(ions of the nerves to the distal pylorus and proxima| duodenum, arising from the helmtie plexus of the left vagus, were unclear (Fig. 24). Some investigators had believed that they were entirely sensory in function, whereas others stated t h a t some fibers contained motor elem e n t s and were in some way concerned in the coordination of gastric emptying. Burge realized the clinical limitations of selective vagotomy alone and emphasized that the operation was contraindicated in eases of distal-antral or duodenal stenosis as well as when performing emergency operations for ulcer. To exclude organic stenosis of the pylorus or duodenum, he did not rely solely on overnight secretory studies or preoperative b a r i u m examinations. More information was gained regarding pylorie patency by passing a cuffed gastric tube through the pyloric outlet at the time of operation." If the tube with or without the cuff could be introduced into the duodenum, then selective vagotomy without drainage was employed. F r o m F e b r u a r y of 1967 to early 1968, Burge23, 26 performed the procedure on 35 patients with satisfactory early results. Up to the present he has carr[ed out selective vagotomy alone in more than 150 patients and is still enthusiastic concerning the results over a relatively short follow-up study. Burge does admit that at times it is difficult to fully evaluate complete pateney of the pyloro-duodenal canal, and he has been misled on occasion by results of several tests. Also, as experience has accumulated, he has employed the selective technic without drainage in eases with minimal to m o d e r a t e duodenal stenosis. Several of his postoperative patients have experienced foul eructations with gastric stasis. In no instance, however, has a gastric ulcer or a recurrent duodenal ulcer deve]Fro. 24.---Selective (gastric) vagotomy without a drainage procedure. E a r l y studies suggest that gastric stasis is a not in'frequent complication.

HEPATC

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39

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oped. Stasis with prolongedi e m p t y i n g has persisted in some p a t i e n t s for several months, a n d this complication has been the m a i n d i s t r a c t i n g feat u r e of t h e operation. Indeed, a few p a t i e n t s have required a subse-luent pyloroplasty. P e r h a p s the g r e a t e s t asset of the o p e r a t i o n to d a t e is its p r e v e n t i o n of s y m p t o m s of the d u m p i n g s y n d r o m e . A longer follow-up s t u d y is strictly in o r d e r before a final a s s e s s m e n t of the o p e r a t i o n can be made. However, should selective vagotomy alone u l t i m a t e l y become an a c c e p t e d operation, t h e n B u r g e believes t h a t it should be considered earlier in the course of ulcer disease, prior to the d e v e l o p m e n t of significant organic changes a r o u n d the d u o d e n u m . 2n S h i i n a and Griffith22-3 found in the canine p r e p a r a t i o n t h a t selective v a g o t o m y without d r a i n a g e resulted in a n t r a l stasis, but H e i d e n h a i n pouch secretion i n c r e a s e d only one-fifth in c o m p a r i s o n to control animals. In c o n t r a s t with total t r u n c a l v a g o t o m y w i t h o u t d r a i n a g e , p r o n o u n c e d stasis o c c u r r e d a n d gastric h y p e r s e c r e t i o n took place. T h e differences in the degree of stasis a n d H e i d e n h a i n pouch secretion a m o n g the two g r o u p s of a n i m a l s could not be related to completeness of v a g o t o m y or lo differences in g a s t r o i n t e s t i n a l motility. It was p o s t u l a t e d t h a t t h e relatively small increase in H e i d e n h a i n pouch secretion after selective v a g o t o m y was due to inhibition of gastric secretion b y : t h e intact h e p a t i c a n d celiac vagi, and t h e large increase in pouch secretion after total t r u n c a l vagotomy was due to e l i m i n a t i o n of this inhibition by division of the h e p a t i c and celiac branches. It should be stressed, however, t h a t some d e g r e e of stasis did occur in the a n i m a l s r e p o r t e d by S h i i n a u n d e r g o i n g selective denervafion alone a n d at times it persisted for several weeks. If this e x p e r i m e n t a l d a t a can in a n y way be t r a n s f e r r e d to the h u m a n , it does indeed s~upport B u r g e ' s clinical investigations, which show t h a t gastric stasis is t h e most p r o m i n e n t complication following selective vagotomy without drainage. C o m p l e t e selective (gas:~ric) d e n e r v a t i o n of necessity divides the vagal b r a n c h e s to the distal a n t r u m and pylorus and conceivably this could account for pyloric d y s f u n c t i o n with r e s u l t a n t stasis. As m e n t i o n e d before, t h e small pyloric n e r v e twigs from the h e p a t i c vagus have been shown to be of no i m p o r t a n c e in r e g u l a t i n g pyloric m u s c u l a r functiol~. I n t e r o n e et aI.112 found t h a t a n i m a l s subjected to selective vagotomy alone i n d e e d developed p r o l o n g e d gastric e m p t y i n g w h e n c o m p a r e d with controls, a n d such an o p e r a t i o n did not protect a g a i n s t histamine-indtlced ulcer. A m d r u p 5 also has b e e n i m p r e s s e d with the long-lasting stasis following selective v a g o t o m y w i t h o u t d r a i n a g e in t h e e x p e r i m e n t a l animal, a n d for t h a t r e a s o n has ~ot applied the o p e r a t i o n on a clinical basis. C u r r e n t l y , selective d e n e r v a t i o n alone is being investigated on a clinical basis largely by B u r g e a n d P r o f e s s o r de Miguel of Spain. Both observers have found t h a t t h e o p e r a t i o n is effective in lowering gastric secretory activity. C o m p l e t e gastric d e n e r v a t i o n u n q u e s t i o n a b l y results in a negative insulin test by s u p p r e s s i o n of the secretory response of t h e p a r i e t a l cell mass, a n d t h e a n t r a l p h a s e of gastric secretion is s o m e w h a t diminished, a p p a r e n t l y by inhibitory influences m e d i a t e d throughl the intact h e p a t i c a n d celiac vagi by w a y of h u m o r a l m e c h a n i s m s from the midgut. S t u d i e s of s e r u m g a s t r i n d e t e r m i n a t i o n s , however, are lacking. T h e results of longt e r m follow-up studies by the above investigators will be a w a i t e d with interest. Burge2s has just recently informed m e t h a t he is now c a r r y i n g 40

out highly selec(ive vagotomy without drainage and has performed 120 such operations.

HIGHLY SELECTIVE VAGOTOMY WITHOUT DRAINAGE Griffith and Harkins,St in 1957, also performed partial gastric vagotomy ira the experimental animal. T h e procedure entailed a selective denervation of only the parietal cell area of the stomach, sparing the innervation to tile a n t r u m and duodenum. It was shown t h a t such an operation did not produce antral stasis, and c o m p l e m e n t a r y drainage was not required. Indeed, these investigators thought that perhaps after f u r t h e r studies the procedure m i g h t be applicable tO the clinical patient. Ferguson spared the vagal innervation to the a n t r u m and proximal d u o d e n u m in performing segmental gastrectomy, but recent studies of his cases by Eisenberg44 have shown a recurrent ulcer rate of 17q:;,. In the late 1960s, Hollel0S, 109 and Hartga of Munich and Hedenstedt96 of Stockholm denervated the parietal cell area in patients with duodenal ulcer but added pyloroplasty in each instance. T h e y termed the vagal denervation a proximal selective vagotom.v. Holle now has performed the procedure in 300 patients and only 2 r e c u r r e n t ulcers have developed.lSn E a c h resulted from incomplete parietal cell denervation. D u r i n g the past several years, both A m d r u p l , ;~, 4,7, s of Copenhagen and Johnston of Leedsl'-'n, 12c,, 1',9. 1,~0 have done extensive experimental work utilizing this type of selective technic. More recently, each has performed the operation in carefully selected clinical cases, always omitting gastric d r a i n a g e . A m d r u p has termed the denervation a parietal cell vagotomy, wherea~ J o h n s t o n prefers to call the operation a highly selective or proximal gastric vagotomy. Even more recently, a few Italian investigatorsl10, 1s7.~07 have coined the terms ultra-selective and acid-fundic selective vagotomy. T h e operation a p p e a r s to possess the advantage of preserving normaI or n e a r - n o r m a l gastric emptying, thereby eliminating s y m p t o m s of the d u m p i n g syndrome. Also, the n e u r o h u m o r a l inhibitory mechanisms of the a n t r u m and d u o d e n u m are left undisturbed. Technically, the operation is a modification of selective (gastric) vagotomy and entails division of the gastric branches of the left and right vagal nerve trunks to the fundocorpal area, but the fibers to the a n t r u m and d u o d e n u m are preserved as are the hepatic and celiac rami6S (Fig. 25). T h e gastric ramification of the left vagal nerve (anterior nerve of Latarjet) usually is more extensive than the right nerve, and it passes distally in the lesser o m e n t u m , with branches entering the a n t e r i o r wall of the lesser gastric curve. T h e posterior nerve of L a t a r j e t lies posteriorly in the lesser o m e n t u m and its branches innervate the posterior wall of the lesser curve. To preserve a n t r a l and pyloric innervation, a combined surgical a p p r o a c h through the lesser o m e n t u m and the gastrocolic ligamer~t has been used by Johnstol~, T h e lesser o m e n t u m is dissected proximally from the lesser curve, keepit~g as close to the stomach as possible. It is i m p e r a tive to guard against the possibility of denervating the proximal a n t r u m so t h a t the dissection is begun a p p r o x i m a t e l y 2 cm. above the determ i n e d antral limit. To define the limits of the proximal a n t r u m , A m d r u p and K r a g e l u n d first stimulate gastric secretion at the time of operation 41

) Fro. 2 5 . ~ H i g h l y selective or parietal cell vagotomy without drainage. This procedure preserves innervation of the gastric antrum ~ well as maintaining the hepatic, celiac and hepatic pyloric innervation intact. Stasis has not been a complication folkr,ving (his operation.

with i n t r a v e n o u s p e n t a p e p t i d e . A nasogastric p H tube is next i n s e r t e d a n d usually a c h a n g e from p H 2 to pI-~ 6 occurs within a 1-cm. m o v e m e n t of the t u b e along t h e lesser curve, t h u s distingTuishing the acid-secreting corpus from the n o n a c i d - s e c r e t i n g : a n t r u m . T h i s is considered t h e proximal limit of the a n t r u m , a n d t h e m e t h o d has the a d v a n t a g e of avoiding gastrotomy. As a n a l t e r n a t i v e , the s t o m a c h m a y be o p e n e d widely along the g r e a t e r curve and s t a i n i n g with Congo red used to d e t e r m i n e the ext e n t of the a n t r a l segment.17s Johnston127 prefers a n a t o m i c l a n d m a r k s a n d d e n e r v a t e s the lesser curve down to a m e a s u r e d 6 cm. from the pyleric ring. T h i s d e n e r v a t i o n p e r h a p s is slightly m o r e extensive t h a n t h a t of A m d r u p , for the l a t t e r leaves 8--10 cm. of the distal lesser curve innervated. A m d r u p a n d K r a g e l u n d p e r f o r m the e n t i r e parietal cell dissection a n t e r i o r l y along t h e lesser curve a n d believe t h a t it is n o t necessary to a p p r o a c h the posterior nerve of L a t a r j e t from behind by dividing the gastrocolic o m e n t u m a n d elevating the stomach. P a r i e t a l cell v a g o t o m y w i t h o u t d r a i n a g e c u r r e n t l y is being employed as a n elective o p e r a t i o n in s i t u a t i o n s in which pyloric stenosis clearly do~,s not exist. J o h n s t o n believes t h a t if the p a t i e n t is free from vomiting during the remissions from ulcer distress, the chances a r e excellent t h a t the s t o m a c h will e m p t y satisfactorily postoperatively. Obviously, if significant gastric r e t e n t i o n exisls p r e o p e r a t i v e l y as evidenced by the presence of food in the s t o m a c h ~fter a n o v e r n i g h t fast, the p r o c e d u r e is contraindicated. I n a r e c e n t c o m m u n i c a t i o n , Johnston12; states t h a t d u r i n g the past 3 y e a r s he h a s p e r f o r m e d the o p e r a t i o n in 110 cases. T h e s p o n t a n e o u s acid o u t p u t has been d i m i n i s h e d by 80% in those p a t i e n t s tested. T h e m e a n acid o u t p u t has been r e d u c e d by 55% and c o n t i n u i n g t e s t i n g shows t h a t this r e d u c t i o n is being m a i n t a i n e d . Insulin test studies, however, have c a u s e d some concern. D u r i n g later follow-up studies, a few early positive a n d some late positive responses have a p p e a r e d , b u t the actual acid outputs have been v e r y low. F r o m his data, he contends t h a t highly selective v a g o t o m y is as effective as t r u n c a l vagotomy in reducing s p o n t a n e o u s a n d m a x i m a l gastric secretion. A m o n g the 110 patients, the operative m o r t a l i t y has been zero, no pa42

tient has required reoperation for stasis a,ld =1o recurrent ulcer has developed over a short follow-up study. T h e r e is no sign of food residues in the postoperative stomach after an overnight fast, and the fasting secretory volumes have been Iow. Gastric e m p t y i n g time with b a r i u m food meals and with isotope-tagged food is only slightly prolonged when compared to controls. J o h n s t o n states t h a t by no means have all his patients obtained perfect:results over a short follow-up study, but his continuing experience is still encouraging. A m d r u p and Griffith~ found in the experimental animal that parietal cell vagotomy without drainage produced no gastric stasis and preserved normal r h y t h m i c e m p t y i n g of the stomach. Postoperative insulin responses were either eliminated or greatly suppressed. However, of some concern was the 24-hour H e i d e n h a i n pouch secretion, which increased by almost 50%. This possibly could be explained by the intragastric rise in p H with e x c e s s r e l e a s e of gastrin from the innervated a n t r u m consequent to a decrease in acid inhibition of the a n t r u m . F u r t h e r observations, however, revealed that no fasting secretion occurred from t h % H e i d e n h a i n pouches, and that the 24-hour secretory rises were due solely to an increased response to feeding. This simply m e a n t that the presence of food in the Fit;. 26.--Graph showing the influence of various technics of vagotomy of gastric ulceration in the rabbit. (Courtesy of E. Amdrup. )

on

the development

No.of rabbits J~

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T,V. : Truncal

vogotomy

S,V..Se/ectJve 9astric vagotom.y H,S.V..Highly selective vagotomy 43

f

Without a drainage

stomach excited the release of more gastrin following parietal cell vagotomy. It was further reasoned that perhaps food in the stomach would buffer the excess acid and prevent ulceration. A m d r u p e t al.5 showed that gastric ulcer formation in the rabbit almost invariably was accomplished by performing truncal vagotomy alone. Selective vagotomy resulted in ulceration in 50% of animals, but no animal developed ulceration following parietal cell vagotomy (Fig. 26). Interone et a1.112 demonstrated experimentally that parietal cell vagotomy alone maintained normal gastric emptying whereas all other types of vagotomy required a drainage-operation. In addition, parietal cell denervatiop, was the only procedure t h a t significantly altered the course of development of a histamine-induced ulcer. Kragelund et al.147-1,~.q have shown from statistical analysis of spontaneous, pentapeptide and insulin-activated gastric acid secretion that the reduction in volume and acidity of total acid output is identical after comp]ete~'selective vagotomy with adequate drainage and parietal ceil vagotomy without drainage (Fig. 27). This could be interpreted to refute the postulate of H a r t that intact antral vagal fibers are inhibitory to the antral segment. Following extensive experimentai studies early in 1969, Amdrup and A m d r u p elected to perform parietal cell vagotomy in man. In a recent communication,5 A m d r u p states that he has c a r r i e d out the procedure in 65 patients. T h e mortality has been nil and no serious complications have occurred. T h i r t y postoperative patients have undergone detailed secretory investigations. T h e m e a n pentapeptide peak acid output (PAO) before o p e r a t i o n w a s 40.3 mEq. and 3 months postoperatively fell to 15.! mEq. M e a n insulin PAO preoperatively was 28.7 mEq. and after operation was 1.4 mEq. T h e spontaneous acid secre*.ion has been reduced 80%. With the passage of time, the pentapeptide peak acid output has, however, shown •

.

/

Fla. 27.--Graph showing n o "-:ignificant difference in spontaneous and augmente(I gastric secretion between selective (gastric) vagotomy with drainage and parietal cell vagotomy without drainage. (Courtesy of E. Kragelund.)

SELECTIVE GASTRIC VAGOTOMY WITH DRAINAGE

PARIETAL CELL VAGOTOMY W I T H O U T DRAINAGE MEQ 12-

MEQ 12

. . . . PEPTAVLON 6 JJg/kg - - - INSULIN 0.2 i.ulkg

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a significant i n c r e a s e up to 18.2 m E q . and likewise the s p o n t a n e o u s acid o u t p u t has .risen 0.5-1.0 mEq. Serial insulin tests likewise have shown an increase d u r i n g the postoperative follow-up, from an early m e a n value of 2.1 mEq. to 6.2 m E q . T h e increases in acid secretions seem to occur m a i n l y in the first 6 m o n t h s following o p e r a t i o n and t h e n become stabilized. A m d r u p thus believes from these observations t h a t parietal cell vagotomy effects a satisfactory reduction in spontaneous, p e n t a p e p t i d e and insulinactivated acid secretion and t h a t as with other types of vagotomy a later increase in the initial level occurs. T h e most plausible explanation for these events, according to A m d r u p , is t h a t r e i n n e r v a t i o n takes place a r o u n d the distal esophageal a r e a a n d along the a n t r o c o r p a l border. Inv e r t i n g silk s u t u r e s have been taken between the a n t e r i o r a n d posterior gastric walls along the lesser curve in the hope of p r e v e n t i n g reinnerration. Clinically, the over-all results have been satisfactory and the o p e r a t i o n seems to have achieved its m a i n objective, t h a t of protection against symptoms of the d u m p i n g s y n d r o m e . In addition, d i a r r h e a has not occurred d u r i n g the follow-up period. One patient, however, developed gastric stasis 3 m o n t h s following o p e r a t i o n a n d s u b s e q u e n t l y developed a gastric ulcer 13 m o n t h s postoperatively desl~ite a negative insulin test a n d m a r k e d reduction in p e n t a p e p t i d e P A O . At re-exploration, no organic basis was found for the gastric delay and the original duodenal ulcer had completely healed. A m d r u p has no e x p l a n a t i o n for tt~is complication. Postoperatively, gastric motility studies d e m o n s t r a t e t h a t the s t o m a c h e m p t i e s a little f:~ster t h a n before operation. T h e gastric tonus in the cardiofundic area is decreased, a n t r a l motility is n o r m a l and small intestinal motility and transit time are not affected (Fig. 28). One p r i m a r y concern to A m d r u p is the i m p o r t a n c e of the exact location of the antrocorl)al border. C a r e m u s t be taken not to d e n e r v a t e the proximal a n t r u m or gastric stasis will take place. F a i l u r e to d e n e r v a t e the distal corpal segm e n t will result in i n c o m p l e t e parietal cell vagotomy. Miller et al.l;6 recently r e p o r t e d a p r e l i m i n a r y study of 25 p a t i e n t s subjected to parietal cell vagotomy, but a F i n n e y pyloroplasty also was added. S i x t e e n of the 25 p a t i e n t s u n d e r w e n t extensive pre- a n d postol)eraiive gastric secretory studies. Basal acid secretion was reduced by 39%, hut in 5 of the 16 patients basal acid rates increased r a t h e r t h a n decreased. T h e m a x i m u m h i s t a m i n e - s t i m u l a t e d secretory rate d r o p p e d 50% following operation, but actually 1 p a t i e n t showed a rise in secretion. N o r e c u r r e n t ulcer has been proved a m o n g the group over a follow-up extellding from 3 m o n t h s to 21/~ years, a n d no p a t i e n t experiences d u m p i n g s y m p t o m s or post vagotomy d i a r r h e a . NyhuslS5 wisely states t h a t the o p e r a t i o n at present is e x p e r i m e n t a l and does not r e c o m m e n d its general use. C u r r e n t l y , the groups at C o p e n h a g e n a n d Leeds are engaged in a, joint siudy, pooling the e x p e r i m e n t a l and cli~)ical d a t a from the two institutions. S h o u l d f u t u r e reports from these groups prove parietal cell vagotomy to be effective over long-range follow-up in p r e v e n t i n g both r e c u r r e n t u l c e r a t i o n and s y m p t o m s of the d u m p i n g s y n d r o m e , a lasting cont~'ibution will have been m a d e to s u r g e r y for ulcer disease. F o r the present, the operative p r o c e d u r e is largely e x p e r i m e n t a l , and its use should be largely restricted to groups such as those at Copenhagen, Leeds and Chicago. 45

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iii

6 FI~. 2 8 . - - A , barium studies of the pyloric channel following parielal ceil v a g o t o m y show little change when compared with the normal subject. B, postopera~iv_~ x-ray studies show no evidence of gastric stasis and no evidence of dilatation of the stomach. (Courtesy of E. Amdrup and E. Kragelund.)

46

TESTS TO DETERMINE THE COMPLETENESS .OF VAGOTOMY T h e r e is no dispute that when vagotomy is used as an integral p a r t of a n y definitive operation for duodenal ulcer, the denervation m u s t be either a d e q u a t e or complete. T h e most widely used test during the postoperative period to determine vagotomy completeness has been the one described by Hollander~0~, 107 or its modification advocated by Stempien.23,t O n e prime objection to the H o l l a n d e r test is t h a t it represents a postoperative evaluation and what the surgeon really needs is a method of determining vagotomy completeness at the operating table. Recently, the H o l l a n d e r test has been open to c r i t i c i s m . S o m e investigators have shown that proved recurrent ulceration is seen as often in patients with a negative H o l l a n d e r response as is seen in those with positive reactions. Some also believe that the positive criterion as laid down by Hollander, which is free acidity elevated to 10 m E q . / L , or 20 m E q . / L , above the fasting level following insulin hypoglycemia, is too rigid. Currently, a n u m b e r of new agents have been used to induce central vagal stimulation, but none appears to be entirely satisfactory.10, ll, 12s, 209,243 T h e H o l l a n d e r test does ~ave certain deficiencies, in that it cannot be employed safely in patients with angina or myocardial disease. Also, no m a t t e r how carefully the test is executed, certain factors as i m p r o p e r position of the n~,sogastric tube, bile regurgitation and extravagal sources of acid stimula~Son serve to modify the results, h{any observers now place g r e a t e r emphasis on postoperative gastric secretorv studies, which include basal acid o u t p u t per hour expressed in m E q . and m e a n a n d m a x i m u m acid o u t p u t with s t i m u l a t o r y drugs. If the basal hourly aci~d o u t p u t exceeds 2 m E q . , the vagotomy is probably incomplete, and if the m a x i m u m acid output is not reduced by at ]east 70,°7o, the vagotomy is likewise probably incomplete. T h o m p s o n and 1Reed,23s in a recent study, a t t e m p t e d to correlate clinical results with the H o l l a n d e r test. A m o n g their patients after vagotomy with pyloroplasty they found a 58.5% incidence of negative responses (114 patients) and a 4 1 ~ incidence of positive responses ( 8 1 patients). In the long-range follow-up of the 114 patients with negative tests, 3 developed a proved recurrent ulcer, and in the group of 81 patients with positive H o l l a n d e r tests only 4 later developed a r e c u r r e n t ulcer. Among 9 additional patients suspected of having a recurrent ulcer, 4 had positive and 5 had negative H o l l a n d e r responses. T h o m p s o n concluded that the s t a n d a r d insulin test m a y have m e r i t in investigating a patient with rec u r r e n t ulcer, but it was of "little value in predicting the future clinical course in a given patient. Most observers who have evaluated the insulin test have reported a high incidence of positive responses u p to 47%. Such responses are not indicative of the future development of recurrent ulceration. If the positive response to insulin, however, occurs early, during the first 45 minutes of testing, such a patient is more likely to develop a rec u r r e n t ulcer t h a n the p a t i e n t who first develops a positive response late in the course of the test. J u d d et al.133 observed no incidence of recurrent ulceration in patients with a negative insulin response, but a positive test was associated with an over-all 60% incidence of recurrence: 69% in the early response group and 43% in the late positive cases. Thus, the results and predictions of the H o l l a n d e r test are both conflicting and confusing. 47

Recently, R e a d et al. in performing the H o l l a n d e r test have used propranolol to eliminate the hazards of h y p o k a l e m i a and adrenergic discharges induced by insulin hypoglycemia. This d r u g in addition was shown to convert 16 posit'ive reactions to negative, thus inhibiting the gastric secretory response t o hypoglycemia. This finding suggested t h a t a f t e r vagotomy the s y m p a t h e t i c nervous s y s t e m plays a role in gastric secretion a n d significantly affects the results of the H o l l a n d e r test. I t is needless to say t h a t a simple i n t r a o p e r a t i v e test to d e t e r m i n e the completeness of vagotomy would be a great asset to the surgeon. In 1958, B u r g e a n d Vane27 devised an electrical stimulation test that m e a s u r e s gastric motility. A circular electrode divided into four q u a d r a n t s is placed a r o u n d the lower esophagus and a cuffed esophagogastric tube is then inflated so t h a t the lower esophagus is sealed a n d the vagal nerves are thus brought into contact with the electrode. By s t i m u l a t i n g the electrode with a square wave impulse at 45 volts, the vagal nerve impulses can be recorded on a w a t e r m a n o m e t e r apparatus. S e g m e n t a l stimulation can be carried out, and by this sensitive device, Burge has been able to record responses even with very fine nerve filaments intact. W h a t Burge considers to be a complete vagotomy in his hands without the electrical test has resulted in a 30/0/o incidence o f incomplete nerve section when the electrical stimulating i n s t r u m e n t was then put into use. Most of the overlooked fibers are extremely small and usually are found embedded anteriorly in the esophageal musculature. Such fibers, on stimulation, give rise to pressure increases of 1/~-11/~ cm. of H 2 0 as recorded on the pressure gauge. I n Burge's hands, the electrical stimulation test has proved worthwhile and has given excellent results.24, 30 However, the procedure is timeconsuming, the a p p a r a t u s is costly and bulky and it has never received wide acclaim. A sophisticated test for completeness of vagotomy has been reported by M c K i b b i n and Naylor.172 T h e test is based on vago-vagal reflex changes in femoral arterial blood pressure with electrical stimulation of the gastric musculature. Needless to say, the test has not received wide acceptance. F r a n k s and Griffen,~9 after a n i m a l experimentation, e m p l o y e d intravenous 2-deoxy-d-glucosel05 in patients to induce gastric contractions prior to c a r r y i n g out vagotomy while the patient was u n d e r anesthesia. Contractions ceased a n d the stomach became flaccid after denervation, but the m a n o m e t r i c s y s t e m employed was both complicated and impractical. These investigators have now abandoned the procedure and are c u r r e n t l y searching for a simple test that can be easily reproducible. I n recent years, Lee ~-53, 15t has employed a r a t h e r fascinating intraoperative test to define the vagal trunks and the s m a l l e r nerve filaments. By a p p l y i n g l e u k o m e t h y l e n e blue to the lower esophageal and proximal gastric walls, the nerve t r u n k s and smaller nerve fibers are stained a distinct d a r k blue or black color, forming a m a r k e d color contrast w i t h the esophageal m u s c u l a t u r e . T h e technic is not a test for complete vagotomy but an aid in assisting the surgeon to effect a satisfactory vagotomy. It is of p a r t i c u l a r benefit in detecting small nerve fibers, which at times, without staining, are invisible to the naked eye. In a p p l y i n g the dye, the perit o n e u m m u s t first be denuded from the anterior esophageal wall. A f t e r dividing the m a i n vagal trunks, the dye is vigorously rubbed over the entire lower esophageal wall with a swab and the excess removed with

48

saline. Vigorous rubbing of the vital dye produces nerve stimulation, which, in turn, results in increased n e u r a l oxygen c o n s u m p t i o n a n d m o r e a d e q u a t e r e d u c t i o n of the ] e u k o m e t h y l e n e blue. T h e technic is effective in c a r r y i n g out both truncal and selective types of denervation. B y utilizing this simple method, L e e has been able to remove nerve fibers, proved by microscopic e x a m i n a t i o n , which otherwise would have been overlooked. C u r r e n t l y , not all observers have been able to r e p r o d u c e Lee's excellent results with this s i m p l e method, as fibrous tissue also has been noted to t a k e up the stain.3.~, 61 Recently,69.7o. 72.7,~. 77 Grassi has employed an i n t r a o p e r a t i v e test based on the evaluation of p H variations in the s t o m a c h a n d the lack of response of the acid-secreting gastric m u c o s a to h i s t a m i n e in the presence of complete vagotomy, T h r o u g h a generous g a s t r o t o m y incision, utilizing a glass probing electrode, he has been able to plot p H values along the length a n d circumference of the acid-secreting m u c o s a before a n d after truncaL selective a n d p a r i e t a l cell vagotomy. I n t e r e s t i n g e x p e r i m e n t a l a n d clinical studies have shown a lack of basal acid secretory response to general anesthesia with the vagi intact. However, with s u b s e q u e n t i n t r a v e n o u s hista-

FIG. 2 9 . w A , following complete gastric denervation, the p H in all parietal cell zones rises to p H 5.5--pH 7. B, an overlooked intact vagal twig in the fundic area is readily apparent b y a p H reading of 1.9 in that particular zone. Following division of the nerve twig, the p H rises to 6.2. C, an overlooked intact vagal twig in the distal corpus is detected b y a p H reading of 2.7 when performing parietal cell vagotomy. Section of the nerve caused an abrupt rise to pI-I 6.4. (Courtesy of G. Grassi.)

/<

I , -

•

•

6.4/ /,,

.

C

49

m i n e a m a r k e d fall in p H occurs ( p H 0.8--pH 1.9) in the fundocorpal portion of the stomach. Following e i t h e r complete selective or c o m p l e t e p a r i e t a l cell vagotomy a n d s u b s e q u e n t h i s t a m i n e stimulation, plotting of the p H values along t h e f u n d o c o r p a l zone t h e n revealed p H variations of from 5.5 to 7. However, in the p r e s e n c e of an overlooked gastric nerve fiber, the p H in t h a t p a r t i c u l a r plotted gastric zone will r e m a i n low in the range of 1.5-2. A s u b s e q u e n t rise in p H to 6-7 will occur following division of t h e overlooked nerve fiber. At present, Grassi71 is enthusiastic with this m e t h o d of d e t e r m i n i n g v a g o t o m y c o m p l e t e n e s s and has p e r f o r m e d the test in 146 patients. T h e a u g m e n t e d h i s t a m i n e test e m p l o y e d p o s t o p e r a t i v e l y has revealed p H wdues similar to those o b t a i n e d at the time of operation. U n q u e s t i o n a b l y , the m e t h o d is a direct assessment of the effect of vagotomy on gastric secretion in c o n t r a s t to B u r g e ' s test, which is an indirect a p p r o a c h testing the influence of d e n e r v a t i o n on gastric motility. Both tests, however, app e a r u n d u l y compli"cated a n d t i m e - c o n s u m i n g a n d their use will, no doubt, be restricted, at least for the present, to centers t h a t are equipped 1o perform them. Lee's m e t h o d of nerve staining a p p e a r s c u r r e n t l y to be lhe m o s t practical solution as an aid in effecting a d e q u a t e vagotomy. Recently. N y h u s has used a n intraoperative, m e t h o d to assess vagotomy completeness. It entails staining the gastric mucosa a n d viewing it via gastroscopy both prior to a n d after denervation. O t h e r s have suggested t h a t p e r h a p s in the f u t u r e s e r u m gastrin levels m a y be of aid in detecting vagoiomy completeness. However, the search for a simple o p e r a t i v e test to e n s u r e complete v a g o t o m y r e m a i n s a challenge.

DISCUSSION T h e vast m a j o r i t y of surgeons c u r r e n t l y recognize four operative procedures t h a t m a y be used to t r e a t the complications of duodenal ulcer: (1) a d e q u a t e distal g a s t r e e t o m y , (2) s u p r a - a n t r a l s e g m e n t a l resection. (3) v a g o t o m y with d r a i n a g e and (4) v a g o t o m y with a conservative distal resection. T h e results of a d e q u a t e gastric resection have now heen thoroughly e v a l u a t e d a n d tested in the U n i t e d S t a t e s for a period exceeding 4 decades. It is t h e belief of m o s t gastric surgeons t h a t the procedure, a l t h o u g h effective in m a n y cases, results in long-range sequelae of significant degree in too large a p e r c e n t a g e of cases. T h e r a t e of r e c u r r e n t ulceration also is a~preciable, a n d m a i n l y for these reasons the o p e r a t i o n has been e m p l o y e d on a m u c h s m a l l e r scale d u r i n g t h e past 15 years. T h e r e are those who c u r r e n t l y contend t h a t t h e p r o c e d u r e should be placed aside a n d referred to only in s u r ~ c a l historical discussions. S u p r a - a n t r a l s e g m e n t a l g a s t r e c t o m y enjoyed a r a t h e r s t r o n g but fleeting period of p o p u l a r i t y after its r e i n t r o d u c t i o n s h o r t l y after W o r l d W a r II. Its advocates soon realized the real d i s a d v a n t a g e s of the operation: too high a r e c u r r e n c e r a t e with a m o d e s t s e g m e n t a l resection and too m a n y crippling sequelae following resection of sufficient m a g n i t u d e to p r e v e n t r e c u r r e n t disease. T h e r e a p p e a r e d to be no middle g r o u n d if aII or most of the a n t r a l s e g m e n t were spared. T h u s , at present, the operation has been practically a b a n d o n e d except in a few surgical c e n t e r s . T h r o u g h o u t the surgical world, with few exceptions, vagotomy :low has 50

been universally a c c e p t e d as an i m p o r t a n t addition to a n y operation designed to control the complications of duodenal ulcer. C u r r e n t l y , vagotomy with d r a i n a g e and vagotomy with a conservative distal resection a r e without question the most widely used operations. F r o m a survey of the literature, t r u n c a l vagotomy with a n t r e c t o m y or h e m i g a s t r e c t o m y now has been rei3orted in several t h o u s a n d p a t i e n t s with a recurrence r a t e of between 0.5% and 1.5~. All agree t h a t the procedure results in the lowest incidence of r e c u r r e n c e of any of the operations in c u r r e n t use. T h e procedure also has p r o d u c e d highly satisfactory results over follow-up periods of f r o m 10. to 24 years. T h e o p e r a t i o n can be p e r f o r m e d electively, in experienced hands, with a m o r t a l i t y of ~./~o or less. T h e disadvantages of the procedure, as voiced by its critics, are t h a t m o r t a l i t y rises to 2 - 3 % in less experienced hands, and the combined o p e r a t i o n is unsafe a n d not applicable to all p a t i e n t s with a severe ulcer process. T h i s indeed is sound criticism, but the o p e r a t i o n can be executed safely in 90-95i~o of patients, including both elective and e m e r g e n c y cases as evidenced by results of reported series. F r o m a s t u d y of the voluminous n u m b e r of articles depicting the results of truncal vagotomy-pyloroplasty, unquestionably the p r o c e d u r e can be performed electively in .experienced h a n d s with an operative m o r t a l i t y of O-0.5.,o or le&n. T h e rate of r e c u r r e n t ulceration varying from 3~o to 23~o, with most observers d e s c r i b i n g i a recurrence rate a r o u n d 10~aZo,would appear to be unacceptable. Also, the reported series in m a n y instances fail to p r e s e n t follow-up d a t a as regards l he fate of p a t i e n t s who s u b s e q u e n t l y develop ulcer recurrence. Of this latter group, a significant n u m b e r will require subseq)~ent o p e r a t i o n a n d the m o r t a l i t y rate for reoperation, particularly in emergency circumstances, is significant, and an u l t i m a t e d e a t h is clearly relaied to the first operation. After a thorough analysis of the m a n y series of r e p o r t e d cases of truncal v a g o t o m y - a n t r e c t o m y and t r u n c a l v a g o t o m y - p y l o r o p l a s t y it would app e a r that one operative procedure should not be e m p l o y e d to the exclusion of the other. I n the good-risk p a t i e n t in w h o m the pathologic process in the d u o d e n u m lends itself to resection, v a g o t o m y - a n t r e c t o m y should be given strong consideration as the o p e r a t i o n of choice. T h e p r e f e r e n c e for resection over pyloroplasty will, of course, increase in the h a n d s of t h e m o r e - e x p e r i e n c e d surgeon. W h e n faced with the high-risk patient, t h e elderly massive bleeder or the p a t i e n t with an intense i n f l a m m a t o r y reaction a r o u n d the duodentun, t r u n c a t ,vagotomy a n d pyloroplasty would a p p e a r to be t h e o p e r a t i o n o f choice. I n p a t i e n t s o p e r a t e d on by t h e lesse x p e r i e n c e d surgeon~ in patients p r e s e n t i n g a lesser degree of ulcer disease a n d with slightly elevated gastric secretory studies, vagotomy a n d pyloroplasty also would seem indicated. T h u s , by not d e n y i n g t h e good-risk p a t i e n t the l a r g e r o p e r a t i o n w h e n all c i r c u m s t a n c e s a p p e a r favorable and by utilizing the lesser p r o c e d u r e in selected cases, the o p e r a t i v e morbidity, m o r t a l i t y a n d r e c u r r e n t ulcer rate m a y be k e p t low with both procedures. Few, if any, a u t h o r i t i e s advocate selective v a g o t o m y - a n t r e c t o m y in view of the low r e c u r r e n t ulcer rate a ~ o c i a t e d with truncal d e n e r v a t i o n in combination with a n t r a l extirpation, a l t h o u g h a d m i t t e d l y !5--30~o of truncal vagotomies a r e incomplete according to t h e postoperative H o l l a n d e r evaluation. W i t h the combined operation, despite the presence of a small overlooked vagal fiber, the t r u n c a l v a g o t o m y m a y be a d e q u a t e a l t h o u g h 51

incomplete. Consideratiort possibly should be given to a p p l y i n g the leukom e t h y l e n e blue s t a i n i n g test to the lower esophageal area when c a r r y i n g out truncal v a g o t o m y - a n t r e c t o m y to e n s u r e a m o r e complete denervation. Selective v a g o t o m y - p y l o r o p l a s t y is w i t h o u t doubt s u p e r i o r to t r u n c a l v a g o t o m y - p y l o r o p l a s t y in p r o t e c t i n g a g a i n s t r e c u r r e n t ulceration. A r e the s u p e r i o r results with the selective technic d u e solely to m o r e complete gastric d e n e r v a t i o n or does a n t r a l g a s t r i n inhibition m e d i a t e d t h r o u g h the i n t a c t hepatic a n d celiac rami play an i m p o r t a n t role? M e a s u r e m e n t s of s e r u m gastrin levels c o m p a r i n g the two opera.~ions would be of e x t r e m e interest. Indeed, s t i m u l a t e d by the reports of such e x p e r t selective vagotomists as Griffith, S a w y e r s a n d others, t h e p r o c e d u r e is now being used electiazely in some centers. It will be of g r e a t i n t e r e s t to observe over the long-range study if selective v a g o t o m y - p y l o r o p l a s t y proves as effective as t r u n c a l v a g o t o m y - a n t r e c t o m y in protecting a g a i n s t ul, cet recurrence. R a n d o m i z e d ' s t u d i e s are~now u n d e r way i n a few institutions. T h e n e w e r operative procedures being s t u d i e d both e x p e r i m e n t a l l y and clinically in a few c e n t e r s t h r o u g h o u t the world a r e of g r e a t interest, and m a y prove to be of s o m e value in the future. T h e d u a l p u r p o s e of each of these operations is to control the ulcer diathesis a n d to afford protection a g a i n s t s y m p t o m s of t h e d u m p i n g s y n d r o m e . M u c o s a l a n t r e c t o m y with selective v a g o t o m y t h u s far has resulted in a low r a t e of r e c u r r e n t u l c e r a t i o n a n d has sufficiently s u p p r e s s e d gastric acidity but has not afforded protection a g a i n s t early p o s t p r a n d i a l s y m p t o m a t o l o g y . Selective (gastric) vagotomy w i t h o u t d r a i n a g e has proved s o m e w h a t effective in centrolling recurrence, b u t gastric stasis has been observed as a f r e q u e n t t r o u b l e s o m e long-range complication. P o s t o p e r a t i v e secretory d a t a also a r e i n c o m p l e t e with this p r o c e d u r e at present. T h e results of parietal ceil v a g o t o m y w i t h o u t d r a i n a g e a p p e a r e n c o u r a g i n g to both A m d r u p and J o h n s t o n , b u t two significant d r a w b a c k s to the o p e r a t i o n are a p p a r e n t : the technical difficulties involved and applicability of the p r o c e d u r e only to selected cases. A l t h o u g h basal a n d a u g m e n t e d gastric secretion a r e red u c e d by the operation, it is u n d e t e r m i n e d at p r e s e n t w h e t h e r this reduction will be sufficient to p r o t e c t against ulcer recurrence. L o n g e r follow-,up studies a r e needed. W i t h both selective a n d p a r i e t a l cell vagotomy, the possible role of a n t r a l inhibition induced t h r o u g h the h e p a t i c and celiac vagi in t h e f o r m e r a n d t h r o u g h tile hepatic, celiac a n d antra] rami in the l a t t e r o p e r a t i o n is not completely understood. V¢ith th~ a n t r u m d e n e r v a t e d in the f o r m e r operation, stasis occurs in the presence of a decreased gastric secretory response. W i t h i n n e r v a t i o n of the a n t r u m m a i n t a i n e d by t h e p a r i e t a l ceil technic a p p a r e n t l y stasis does not occur even in the presence of a n increased gastric secretory response to feeding. M e a s u r e m e n i s of a n t r a l gastrin levels also would be of g r e a t i n t e r e s t in f u r t h e r e w d u a t i n g t h e two operative procedures. S u p r a - p y l o r i c a n t r e c t o m y with selective v a g o t o m y a n d with a m i n i - p y I o r o p l a s t y a p p e a r s to have merit, and its indications m a y be b r o a d e n e d in the future. T h i s p r o c e d u r e a p p e a r s thus far to a d e q u a t e l y s u p p r e s s gastric secretory activity a n d to aboli:;h symptom~ of the d u m p i n g s y n d r o m e . It is hoped t h a t both e x p e r i m e n t a l and clinical research will c o n t i n u e with these new fascinating operative procedures but, for the present, truncal v a g o t o m y - a n t r e c t o m y and truncal v a g o t o m y - p y l o r o p l a s t y continue to be the most p o p u l a r and widely used o p e r a t i o n s for control of duoden:tl 52

ulcer. Only by wisely selecting the patients for the proper operaf~ive procedure can we diminish the morbidity and mortality and improve the long-range results.

SUMMAR'Y T h e accepted operations used to control the complications of duodenal ulcer have been described and the results cited in detail. Less frequently e m p l o y e d operations also have been m e n t i o n e d and the results tabulated. N e w e r surgical procedures d e v e l o p e d recently in certain surgical centers and directed toward combating the ulcer diathesis and controlling s y m p t o m s of the d u m p i n g s y n d r o m e have been described. It is emphasized that these operations are by no m e a n s ready for widespread clinical use. At present, the operations of truncal v a g o t o m y - a n t r e c t o m y and truncal or selective v a g o t o m y with pyloroplasty are the surgical m a i n s t a y s in controlling the complications of duodenal ulcer.

ACKNOWLEDGMENTS I wish to express m y deepest gratitude to each of m y surgical colleagues referred to in the m o n o g r a p h without whose assistance this review would have been impossible. Special gratitude is due Dr. Charles Griffith of Seattle, Mr. Jerry Kirk of London, Mr. Walter J o h n s t o n of Leeds and Professors Erik A m d r u p and Ebbe Kragelund of Copenhagen. Appreciation is extended ~o the artist, Mrs. A n n e Rees, and also m y secretary, Mrs. D o r o t h y Huff. I am extremely grateful to m y dear wife, Mamie, for reading and correcting the manuscript. REFERENCES .

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