- Email: [email protected]
Parietal Cell Vagotomy
Symposium on Modern Techniques in Surgery
Parietal Cell Vagotomy
Ricardo L. Rossi, M.D.* and John W. Braasch, M.D.*
Dragstedt and Owens demonstrated in 1943 that truncal vagotomy in patients with duodenal ulcer abolished the gastric hypersecretion and inappropriate nocturnal acid secretion with healing of the ulcer. 11 The problem of gastric stasis after truncal vagotomy alone led to the combination of this operation with a gastric drainage procedure. In these patients, the lack of the regulatory mechanism of gastric emptying associated with the denervation of viscera other than the stomach produced a small but appreciable number of complications, such as dumping, diarrhea, and weight loss. Selective gastric vagotomy, initially described by Latarjet, 33 was reintroduced by Jackson 25 and Franksson 12 with vagal denervation of the entire stomach and preservation of the extragastric vagal branches in an attempt to decrease some of the side effects. There is evidence that selective vagotomy reduces the incidence of diarrhea. 28 However, truncal vagotomy and antrectomy became, for many surgeons, the procedure of choice for patients with a duodenal ulcer because of the low recurrence rate of approximately 1 per cent. This compares favorably with the estimated 10 per cent recurrence rate after truncal vagotomy and drainage. 14 A resection procedure, however, has a higher operative mortality rate, especially in high-risk surgical patients.28 Although these procedures have been effective in the treatment of duodenal ulcer, the undesirable side effects leave room for improvement. In 1957 Griffith and Harkins described the technique of partial gastric vagotomy in dogs, interrupting those vagal fibers that supply the acidpepsin secreting fundus and corpus of the stomach but saving the fibers to the antropyloric complex (Fig. 1). 19 This procedure eliminated the cephalic phase of gastric secretion but did not interfere appreciably with gastric emptying. Holle and Hart first reported the use of parietal cell vagotomy in humans but added a drainage procedure negating, in part, the advantages of this type of vagotomy. 21 Amdrup and Jensen 2 and Johnston and Wilkinson 29 also carried out this procedure in humans but preserved the integrity of the pylorus. '''Department of Surgery, Lahey Clinic Foundation, Boston, Massachusetts
Surgical Clinics of North America- Vol. 60, No.2, April 1980
247
~o .. ~. ''''"·•"""·" . - .
248
RICARDO
Figure 1.
L.
RosSI AND jOHN
W.
BRAASCH
Types of vagotomy: a, truncal; b, selective; and c, highly selective parietal cell
vagotomy.
It has been postulated31 that the potential advantages of parietal cell vagotomy include low operative mortality and morbidity, an innervated pylorus and antrum that may provide nearly normal gastric emptying, possible preservation of inhibitory effects on acid secretion by the intact extragastric and antral branches of the vagus nerves, maintenance of a functioning pylorus, which may reduce duodenal reflux into the stomach, and preservation of duodenal innervation without interfering with the normal release of duodenal hormones.
ANATOMY OF VAGUS NERVES The left vagus nerve (Fig. 2) continues anteriorly in the lesser omentum parallel to the lesser curvature of the stomach at about 1 to 2 em from it, forming the anterior nerve of Latarjet. 19• 36 It reaches the pyloric antral area where it fans out into branches forming the "crow's foot" that is generally within 7 em of the pyloroduodenal junction. The anterior vagus nerve supplies the hepatic branch to the gallbladder and biliary tree.
249
pARIETAL CELL VAGOTOMY
_..~Anterior
vagal n.
Hepatic br.
Ant. nerve of Latarjet
Figure 2.
Anatomy of the anterior vagus nerve.
The right vagus nerve (Fig. 3) continues in the posterior aspect of the lesser omentum, formi:rig the posterior nerve of Latarjet and having a position similar to that of the anterior nerve. Early in its course, a branch to the celiac plexus supplies vagal fibers to the bowel and other abdominal viscera.
SURGICAL TECHNIQUES We use a modification of the technique described by Goligher.' 3 Exposure of the proximal stomach and distal esophagus is critical in the performance of this operation. A midline incision extends from along the xiphoid process to the umbilicus. The falciform ligament is divided and ligated, and the abdomen is explored. The bladder blade of a Balfour retractor is placed substernally and tied over the ether screen to the operating table by the anesthesiologist with a sterile, double-fold strip of cloth or gauze, thereby increasing access to the upper abdominal and subdiaphragmatic space (Fig. 4). A regular Balfour retractor is used in the lower half of the incision. The operating table is placed in the reverse Trendelenburg position of approximately 15 to 20 degrees to give countertraction to the substernal retractor and to allow the abdominal contents to descend.
r 250
RICARDO
L.
ROSSI AND ]OHN
...-Celiac br. /
-----Post. nerve _---of Latarjet
Grow's foot / /
/
Figure 3.
Anatomy of the posterior vagus nerve.
W.
BRAASCH
r
pARIETAL CELL VAGOTOMY
251
Figure 4. The bladder blade of a Balfour retractor is placed substernally and tied over the ether screen to the operating table.
The anterior nerve of Latarjet and the hepatic branch of the anterior vagus nerve are identified. The gastrohepatic ligament is opened without damaging these structures to allow for retraction of the lesser omentum by the left hand of the operating surgeon (Fig. 5A). The first assistant retracts the stomach with the left hand by grasping a large intragastric tube. We do not routinely incise the triangular ligament of the left lobe of the liver or isolate the main vagus trunks at this stage, although this may be a useful technique for surgeons who are beginning to use this procedure. When the craw's foot is identified, dissection of the anterior leaf of the gastrohepatic ligament is begun not closer than 7 em from the pylorus (Fig. 5B). Dissection is carried out close to the stomach to avoid injury to the nerve of Latarj et. Each vessel with its accompanying nerve branch is ligated in continuity on the omental side and is clamped on the stomach side (Fig. 6). The vessels and nerve branches are thereafter transected and ligated on the stomach side (Fig. 7). We avoid the temptation of using coagulation or clips because of frequent bleeding associated with these hemostatic procedures. The dissection is contin-
r
\lklldli.IOJII.II~ ...........iioillliiii--IO-IIC'"'"--""''""""'"
I, II
252
RICARDO
L.
RoSSI AND joHN
W.
BRAASCH
Figure 5. A, Exposure of lesser curvature of stomach and nerve of Latarjet. Surgeon's left hand retracts gastrohepatic ligament while the first assistant retracts the stomach by grasping the nasogastric tube. B, Dissection of the anterior leaf of gastrohepatic ligament is begun at the left of the crow 1s foot approximately 7 em from the pylorus.
pARIETAL CELL VAGOTOMY
253
Figure 6. Dissection is accomplished close to the stomach. A, Each vessel is ligated in continuity at the side of the left gastric artery and (B) clamped on the stomach side.
ued cephalad toward the gastroesophageal area (Fig. SA). When dissection allows easy visibility of the posterior leaf of the gastrohepatic ligament, its vessels can be clamped and transected using the same precautions as with the anterior leaf (Fig. 8B ). The lesser sac is entered. A Penrose drain placed in the rent of the gastrohepatic ligament aids in its retraction for better exposure of its vessel and nerve fibers thereby avoiding injury to the nerve of Latarjet. The dissection is continued toward the angle of His. Frequently, a fat pad overlying the gastroesophageal area indicates the line of dissection (see Fig. 8B). The dissection is continued around the esophagus; the
Figure 7.
A and B, Vessels are transected and ligated on the stomach side.
254
RICARDO
L.
Rossi AND]OHN
W.
BRAASCH
Figure 8. A, Dissection is carried out close to the stomach and extended cephalad toward the gastroesophageal area, exposing the posterior leaf of the gastrohepatic ligament. B, Posterior leaf of the gastrohepatic ligament is divided, and the lesser sac is entered. Dissection is continued toward the angle of His. C, Dissection of the lower esophagus is begun and extended to the first short gastric vessel.
pARIETAL CELL VAGOTOMY
255
Figure 8 Continued. D, Esophagus is retracted, and the posterior vagal branches are transected. E, Esophageal dissection is extended cephalad for 5 to 7 em from the gastroesophageal junction.
256
RICARDO
L.
Rossr AND joHN
W.
BRAASCH
lesser omentum is always retracted toward the right to avoid injury to the main vagal trunks. The greater curvature is dissected up from the esophagus to the first short gastric vessel (Fig. 8C). At this stage, the esophagus is retracted anteriorly, and any branches found in the posterior wall of the esophagus and esophagogastric junction are dissected and transected (Fig. 8D). The esophagus is dissected for 5 to 7 em, isolating it completely from the vagal branches (Fig. 8E). Once hemostasis is insured, the extent of vagal denervation is reassessed. The distance between the pylorus and the site of dissection in the lesser curvature is measured to make sure that the posterior leaf of the lesser omentum has been divided to the same extent as has the anterior leaf. We do not routinely open the gastrocolic ligament in our operation, but this can be performed either for dissection of the posterior leaf of the lesser omentum or to assess the extent and adequacy of the dissection. Dissection of the distal esophagus is one of the key factors in the success of this operation. We do not include any antireflux procedure unless a specific preoperative indication is present. We do not routinely imbricate the lesser curvature of the stomach.
Pyloric Dilatation When pyloroduodenal stenosis exists, as assessed by the preoperative barium study of the upper gastrointestinal tract or endoscopy, symptoms of gastric outlet obstruction, or operative findings, dilatation is considered. For this, a longitudinal gastrostomy is performed near the pylorus and close to the greater curvature to avoid denervation of the antrum (Fig. 9). It is made of a size that allows the introduction of one finger. Introduction of the index finger helps to assess the extent of stenosis and the degree of fibrosis or edema. The finger is advanced gently into the duodenum. A number 18 Hegar dilator can be used. Occasionally a small tear of the duodenal wall occurs with this procedure; it should be looked for and, if found, closed in a transverse fashion.
RESULTS For a procedure to be accepted as new therapy for ulcer disease, it must be associated with some major improvement, such as a lower operative mortality and operative morbidity, a lower incidence of late side effects, or a lower recurrence rate, and it must have technically reproducible results.
Operative Mortality and Morbidity A worldwide survey of results of more than 5000 highly selective vagotomies performed electively for duodenal ulcer gave an operative mortality rate of 0.3 per cent. 28 This was lower than that found in collected series after vagotomy with drainage (0.8 per cent) or after gastric resection with or without vagotomy (more than 1 per cent) - differences that are highly significant statistically.
PARIETAL CELL VAGOTOMY
257
Figure 9. Pyloroduodenal dilatation. A, A small gastrostomy is performed close to the pylorus and to the greater curvature. B, The pyloroduodenal area is assessed by palpation. Gentle finger dilatation is performed. C, Gastrostomy is closed.
Necrosis of the lesser curvature of the stomach occurred in 0.2 per cent of patients and was responsible for death in half of them (0.1 per cent). 27 This represents a specific complication of highly selective vagotomy. Its pathogenic mechanism is unclear, but it has been thought to be related to ischemia from devascularization of the lesser curvature or from ligatures that include part of the gastric wall. A higher incidence of this complication has been reported when highly selective vagotomy is used prophylactically for duodenal ulcer in patients who are to undergo renal transplantation. 27 To avoid this complication, reperitonealization of the lesser curvature of the stomach has been recommended 8 after highly selective vagotomy, but it has not achieved widespread accept-
258
RICARDO
L.
ROSSI AND ]OHN
W.
BRAASCH
ance. Splenectomy for surgical trauma is required in less than 5 per cent of patients. 1 Esophageal perforation has also occurred. 1
Side Effects DuMPING. It is well accepted that dumping occurs rarely after this procedure, with an incidence of less than 5 per cent in most published series. 1· 15 · 17 • 23 · 38 When proximal gastric vagotomy is associated with pyloroplasty, the incidence of dumping increases greatly. 40 DIARRHEA. This side effect is not a problem with parietal cell vagotomy, having an incidence that fluctuates between 0 and 3 per cent. 1· 15· 30 Diarrhea and dumping appear to be of mild or moderate severity and to subside within two years in most patients. When comparing other side effects, such as postprandial epigastric fullness and vomiting of bile, Goligher et al. found no appreciable difference after highly selective vagotomy, truncal vagotomy, and drainage or antrectomy.15 DELAYED GASTRIC EMPTYING. Symptoms suggesting gastric stasis, such as epigastric fullness, bloating, and hiccups, occurred early in the postoperative period in 0 to 30 per cent of patients who had undergone parietal cell vagotomy.27. 38 The symptoms do not seem to be more frequent than with other ulcer operations and tend to subside in most patients by two months from the time of operation. Gastric emptying for solids is normal after this procedure, 6 • 22 but early gastric emptying of liquids has been faster 24 or unchanged. 7In patients who have undergone parietal cell vagotomy and pyloric dilatation for pyloric stenosis, symptomatic improvement occurs early, but radiographic findings of delayed gastric emptying can take as long as 12 months before complete return to normal. 10 / GASTROESOPHAGEAL REFLUX. Some surgeons suggest that since parietal cell vagotomy may be associated with a high incidence of postoperative gastroesophageal reflux, a simultaneous antireflux procedure should be added. 37· 39 Csendes demonstrated that denervation of the cardia and the lower part of the esophagus did not influence the lower gastroesophageal sphincter pressures or produce gastroesophageal reflux as determined by the pH glass electrode. 9 Therefore, it does not appear advisable to perform routine antireflux procedures in patients undergoing parietal cell vagotomy. This concurs with our experience. 5 When the presence of gastroesophageal reflux is established by careful preoperative evaluation, including manometric or acid reflux studies, an antireflux procedure would be indicated at the time of parietal cell vagotomy. Recurrence Rates and Effects of Parietal Cell Vagotomy on Gastric Acid Production In most published reports, highly selective vagotomy consistently abolishes the acid response to insulin early after operation (one week), but on serial testing at five years postoperatively, approximately 90 per cent of patients will have positive responses to insulin using Hollander's
pARIETAL CELL VAGOTOMY
259
criteria. 35 With selective vagotomy or truncal vagotomy, positive results to the Hollander test have been found in up to 50 per cent of patients. The decrease in gastric acid production is appreciable. During the first months after vagotomy, acid production progressively increases but stabilizes between one and five years postoperatively. 4 By five years, reduction in basal acid output is 80 per cent, and that of maximal acid output and peak acid output after pentagastrin is approximately 50 per cent. 18 The recurrence rate for duodenal ulcer after highly selective vagotomy is not well known, as long-term follow-up studies are necessary and only a few large series have follow-up data for more than five years. Recurrence rates vary between 4 and 10 per cent,4 • 15 but recurrence rates as high as 20 per cent have been reported. 34 In a series of II7 patients studied for five to eight years, the recurrence rate was 4.3 per cent. 15 It is estimated that the long-term recurrence rate of ulcer after parietal cell vagotomy will be similar to that found after truncal vagotomy and will approach 10 per cent. 4 Several factors appear to be related to the incidence of recurrence. Technical aspects are of importance. The degree of vagal denervation has been determined by anatomic landmarks as described by Goligher, 13 by using Congo red stain or by using an intragastric pH probe as described by Amdrup et aP and Grassi. 16 All of these techniques appear equally effective in determining the distal limit of denervation as long as dissection is begun less than 10 em from the pylorus. In contrast, proximal vagal denervation is critical. When esophageal dissection is carried only for a short distance, a high incidence of early postoperative positive results on the Hollander test and a recurrence rate of 20 per cent or more are recorded. 20 • 34 If denervation is extended 5 to 7 em proximal to the esophagogastric junction, the recurrence rate is decreased. The best result is accomplished by a dissection carried out as close to the stomach as possible, that is, started at the left of the craw's foot at approximately 7 em from the pylorus and extended proximally around the esophagus for 5 to 7 em with careful dissection of posterior esophagogastric branches. The selection of patients to undergo this operation can be important. Wastell et al. noted that recurrence rates after proximal gastric vagotomy are higher in patients who have hypersecretion with a peak acid output after pentagastrin of more than 35 mM an hour. 40 These findings have not been demonstrated in other series. 28 Some evidence indicates that the recurrence rate after proximal gastric vagotomy is higher when the procedure is used for gastric ulcer than when it is used for duodenal ulcer, 4 which brings into question the use of the operation in the former circumstance. The Hollander test and other tests for gastric acid secretion have been used to assess the success of parietal cell vagotomy. Although an early positive Hollander test (one week) has been related to a higher incidence of recurrence, 28 none of these studies has proved to help consistently in identifying the patient with a high likelihood for recurrence or as a criterion for an adequate technical procedure. 26 Ulcers
260
RICARDO
L.
ROSSI AND JOHN
W.
BRAASCH
recur both in patients with positive and those with negative responses to the Hollander test.
Overall Results Using a modification of the Visick classification, Goligher and Hill rated their five-year to eight-year results as excellent or very good (Visick I and II) in 75 per cent of patients, as fair (Visick III) in 13 per cent of patients, and as failures (Visick IV) in 12 per cent of patients. 15 Amdrup et al. 1 reported good or excellent results in 83 per cent of their patients with a follow-up review of two years, whereas Grassi 17 noted similar results in more than 90 per cent of patients. Lahey Clinic Experience At the Lahey Clinic we have reviewed, but not yet reported on, our first 53 patients who have undergone parietal cell vagotomy with a median follow-up period of 30 months (range, 12 to 57 months). The main surgical indication was intractability, although one-third of our patients had different degrees of pyloroduodenal obstruction that required dilatation. More than 80 per cent of our patients had an excellent or very good result, according to the Visick grading as modified by Goligher et al. 14 (Table 1). For patients treated for intractability, the recurrence rate was 3 per cent, but in those with preoperative gastric outlet obstruction, it was more than 10 per cent. Most of the recurrences have been controlled with medical therapy. Dumping and diarrhea were not problems, and symptoms suggestive of delayed gastric emptying resolved in all patients.
Table 1. Overall Grading of Results (Modified Visick Classification)':' CATEGORY
I. Excellent II. Very good
III. Satisfactory
IV. Unsatisfactory
DEFINITION
Absolutely no symptoms; perfect result Patient considers result perfect, but interrogation elicits mild occasional symptoms easily controlled by minor adjustment in diet Mild to moderate symptoms not controlled by care causing some discomfort, but patient and surgeon satisfied with result, which does not interfere seriously with life or work Moderate or severe symptoms or complications that interfere considerably with work or enjoyment of life; patient or physician dissatisfied with result; includes all patients with proved recurrent ulcer and those submitted to further operation, even though the latter may have been followed by considerable symptomatic improvement
*Modified by Goligher, J. C., Feather, D. B., Hall, R., et al.: Several standard elective operations for duodenal uicer: Ten to 16 year clinical results. Ann. Surg., 189:18-24, 1979.
261
pARIETAL CELL VAGOTOMY
INDICATIONS
'i , I
The primary indication for parietal cell vagotomy is in the elective management of patients with duodenal ulcer in whom the surgical indication is intractability. Highly selective vagotomy has also been performed occasionally in association with suture plication of perforated duodenal ulcers 32 in good surgical risk patients who had exploratory laparotomy soon after the perforation had occurred and had minimal findings of peritonitis. It has also been employed in association with suture ligation for a bleeding ulcer. 28 Pyloroduodenal dilatation and parietal cell vagotomy have been reported 10 in the management of patients with duodenal ulcer and gastric outlet obstruction. We must realize, though, that experience in the management of the complications of duodenal ulcer by parietal cell vagotomy is limited, patient selection is important, and in the presence of a complication this procedure should probably not be attempted except by surgeons who have had experience with this technique.
CONCLUSION Since Amdrup and Jensen 2 and Johnston and Wilkinson 29 first carried out parietal cell vagotomy with preservation of the pylorus as had been described in dogs by Griffith and Harkins, 19 important experience with this procedure has been accumulated. Although long-term followup data to assess clearly the advantages and disadvantages of this procedure have still not been obtained, it appears that the low operative mortality and morbidity and the low incidence of side effects, such as dumping and diarrhea, are withstanding the test of time. The recurrence rate increases with the length of the follow-up period, but it is estimated that it will approach that of truncal vagotomy and drainage and be in the range of 10 per cent. So far, the majority of patients who have a recurrent ulcer improve on medical therapy and only a minority require reoperation. Technical aspects appear clearly related to the incidence of ulcer recurrence. We believe good results are to be expected when the dissection is begun at the left of the crow's foot at approximately 7 em from the pylorus, is carried proximally as close to the stomach as possible, and is continued around the esophagus for a distance of 5 to 7 em, with a careful watch for the posterior branches in the esophagogastric area. Close clinical follow-up study of these patients is the best way to determine the success of the operation. Studies of gastric acid have not been able to identify consistently those patients who are at high risk of recurrence or to determine the technical adequacy of the vagotomy. When symptoms of delayed gastric emptying occur, they are mild and transient. The main indication for this procedure is intractable duodenal ulcer. The use of this procedure in the presence of perforation or active
262
RICARDO
L.
ROSSI AND jOHN
W.
BRAASCH
bleeding requires a high degree of patient selection and should be reserved for those surgeons who have important experience with parietal cell vagotomy. Parietal cell vagotomy could be less successful for gastric ulcer than for duodenal ulcer, and we cannot recommend this procedure for gastric ulcer at the present time. Although the procedure is not a technically demanding operation, its subtleties are best learned in the operating room from someone with expertise in the procedure. Patients who have undergone parietal cell vagotomy require close long-term follow-up care.
REFERENCES 1. Amdrup, E., Andersen, D., and Hl')strup, H.: The Aarhus County vagotomy trial. I. An interim report on primary results and incidence of sequelae following parietal cell vagotomy and selective gastric vagotomy in 748 patients. World J. Surg., 2:85-90, 1978. 2. Amdrup, E., and Jensen, H. E.: Selective vagotomy of the parietal cell mass preserving innervation of the undrained antrum: A preliminary report of results in patients with duodenal ulcer. Gastroenterology, 59:522-527, 1970. 3. Amdrup, E., Jensen, H. E., Johnston, D., et al.: Clinical results of parietal cell vagotomy (highly selective vagotomy) two to four years after operation. Ann. Surg., 180:279-284, 1974. 4. Andersen, D., Hl')strup, H., and Amdrup, E.: The Aarhus County vagotomy trial. II. An interim report on reduction in acid secretion and ulcer recurrence rate following parietal cell vagotomy and selective gastric vagotomy. World J. Surg., 2:91-99, 1978. 5. Braasch, J. W., Sala, L. E., Ellis, F. H., Jr., et al.: Effect of parietal cell vagotomy on lower esophageal sphincter function. Arch. Surg. (in press). 6. Brandsborg, 0., Brandsborg, M., Ll')vgreen, N. A., et al.: Influence of parietal cell vagotomy and selective gastric vagotomy on gastric emptying rate and serum gastrin concentration. Gastroenterology, 72:212-214, 1977. 7. Clarke, R. J., and Alexander-Williams, J.: The effect of preserving antral innervation and of a pyloroplasty on gastric emptying after vagotomy in man. Gut, 14:300-307, 1973. 8. Croft, R. J.: Reperitonealization and invagination of the lesser curvature of the stomach following proximal gastric vagotomy. Arch. Surg., 113:206-207, 1978. 9. Csendes, A., 0ster, M., Ml')ller, J. T., et al.: Gastroesophageal reflux in duodenal ulcer patients before and after vagotomy. Ann. Surg., 188:804-808, 1978. 10. Delaney, P.: Preoperative grading of pyloric stenosis: A long term clinical and radiological follow-up of patients with severe pyloric stenosis treated by highly selective vagotomy and dilatation of the stricture. Br. J. Surg., 65:157-160, 1978. 11. Dragstedt, L. R., and Owens, F. M., Jr.: Subdiaphragmatic section of vagus nerves in treatment of duodenal ulcer. Proc. Soc. Exp. Biol. Med., 53:152-154, 1943. 12. Franksson, C.: Selective abdominal vagotomy. Acta. Chir. Scand., 96:409-412, 1948. 13. Goligher, J. C.: A technique for highly selective (parietal cell or proximal gastric) vagotomy for duodenal ulcer. Br. J. Surg., 61:337-345, 1974. 14. Goligher, J. C., Feather, D. B., Hall, R., et al.: Several standard elective operations for duodenal ulcer: Ten to 16 year clinical results. Ann. Surg., 189:18-24, 1979. 15. Goligher, J. C., Hill, G. L., Kenny, T. E., et al.: Proximal gastric vagotomy without drainage for duodenal ulcer: Results after 5-8 years. Br. J. Surg., 65:145-151, 1978. 16. Grassi, G.: Highly selective vagotomy with intra-operative acid secretive test of completeness of vagal section. Surg. Gynecol. Obstet., 140:259-264, 1975. 17. Grassi, G., Orecchia, C., Cantarelli, I., et al.: Results of highly selective vagotomy in our experience (787 cases). Chir. Gastroenterol. 11 :51-58, 1977. 18. Greenall, M. J., Lyndon, P. J., Goligher, J. C., et al.: Long term effect of highly selective vagotomy on basal and maximal acid output in man. Gastroenterology, 68:1421-1425, 1975. 19. Griffith, C. A., and Harkins, H. N.: Partial gastric vagotomy: An experimental study. Gastroenterology, 32:96-102, 1957. 20. Hallenbeck, G. A., Gleysteen, J. J., Aldrete, J. S., et al.: Proximal gastric vagotomy: Effects of two operative techniques on clinical and gastric secretory results. Ann. Surg., 184:435-440, 1976. 21. Holle, F., and Hart, W.: Neue Wege der Chirurgie des Gastroduodenalulkus. Med. Klin., 62:410-450, 1967.
pARIETAL CELL VAGOTOMY
263
22. Howlett, P. J., Ward, A. S., and Duthie, H. L.: Gastric emptying after vagotomy. Proc. R. Soc. Med., 67:836-838, 1974. 23. Humphrey, C. S., Johnston, D., Walker, B. E., et al.: Incidence of dumping after truncal and selective vagotomy with pyloroplasty and highly selective vagotomy without drainage procedure. Br. Med. J., 3:785-788, 1972. 24. Humphrey, C. S., Wilkinson, A. R., and Johnston, D.: The correlation between the rate of gastric emptying and dumping and diarrhoea after truncal, selective, and highly selective vagotomy. Br. J. Surg., 59:309, 1972. 25. Jackson, R. G.: Anatomic study of vagus nerves with a technic of transabdominal selective gastric vagus resection. Arch. Surg., 57:333-352, 1948. 26. Jaffe, B. M.: Parietal cell vagotomy: Surgical technique, gastric acid secretion, and recurrence. Surgery, 82:284-286, 1977. 27. Johnston, D.: Operative mortality and postoperative morbidity of highly selective vagotomy. Br. Med. J.,4:545-547, 1975. 28. Johnston, D., and Goligher, J. C.: Selective, highly selective, or truncal vagotomy? In 1976-a clinical appraisal. SURG. CLIN. NORTH AM., 56:1313-1334. 1976. 29. Johnston, D., Wilkinson, A. R.: Highly selective vagotomy without a drainage procedure in the treatment of duodenal ulcer. Br. J. Surg., 57:289-296, 1970. 30. Jordan, P. H., Jr.: A prospective study of parietal cell vagotomy and selective vagotomy- antrectomy for treatment of duodenal ulcer. Ann. Surg., 183:619-626, 1976. 31. Jordan, P. H., Jr.: Current status of parietal cell vagotomy. Ann. Surg., 184:659-671, 1976. 32. Jordan, P. H., Jr., and Korompi, F. L.: Evolvement of new treatment for perforated duodenal ulcer. Surg. Gynecol. Obstet., 142:391-395, 1976. 33. Latarjet, A.: Resection of nerves of stomach. Bull. Acad. de Med.,87:681-691, 1922. 34. Liedberg, G., and Oscarson, J.: Selective proximal vagotomy: Short time follow-up of 80 patients. Abstract. Scand. J. Gastroenterol., 8(Suppl20):12, 1973. 35. Lyndon, P. J., Greenan, M. J., Smith, R. B., et al.: Serial insulin tests over a five-year period after highly selective vagotomy for duodenal ulcer. Gastroenterology, 69:11881195, 1975. 36. McCrea, E. D.: The abdominal distribution of the vagus. J. Anat., 59: 1S-40, 1924. 37. Sankar, M. Y., Old, J. M., Trinder, P., et al.: The advantages of combining posterior gastropexy with proximal gastric vagotomy. Chir, Gastroenterol., 10:389-392, 1976. 38. Sawyers, J. L., Herrington, J. L., and Burney, D. P.: Proximal gastric vagotomy compared with vagotomy and antrectomy and selective gastric vagotomy and pyloroplasty. Ann. Surg., 186:510-515, 1977. 39. Temple, J. G., and McFarland, J.: Castro-oesophageal reflux complicating highly selective vagotomy. Br. Med. J., 2:168-169, 1975. 40. Wastell, C., Colin, J., Wilson, T., et al.: Prospectively randomised trial of proximal gastric vagotomy either with or without pyloroplasty in treatment of uncomplicated duodenal ulcer. Br. Med. J., 2:851-853, 1977. Lahey Clinic Foundation 605 Commonwealth Avenue Boston, Massachusetts 02215
Parietal Cell Vagotomy
Ricardo L. Rossi, M.D.* and John W. Braasch, M.D.*
Dragstedt and Owens demonstrated in 1943 that truncal vagotomy in patients with duodenal ulcer abolished the gastric hypersecretion and inappropriate nocturnal acid secretion with healing of the ulcer. 11 The problem of gastric stasis after truncal vagotomy alone led to the combination of this operation with a gastric drainage procedure. In these patients, the lack of the regulatory mechanism of gastric emptying associated with the denervation of viscera other than the stomach produced a small but appreciable number of complications, such as dumping, diarrhea, and weight loss. Selective gastric vagotomy, initially described by Latarjet, 33 was reintroduced by Jackson 25 and Franksson 12 with vagal denervation of the entire stomach and preservation of the extragastric vagal branches in an attempt to decrease some of the side effects. There is evidence that selective vagotomy reduces the incidence of diarrhea. 28 However, truncal vagotomy and antrectomy became, for many surgeons, the procedure of choice for patients with a duodenal ulcer because of the low recurrence rate of approximately 1 per cent. This compares favorably with the estimated 10 per cent recurrence rate after truncal vagotomy and drainage. 14 A resection procedure, however, has a higher operative mortality rate, especially in high-risk surgical patients.28 Although these procedures have been effective in the treatment of duodenal ulcer, the undesirable side effects leave room for improvement. In 1957 Griffith and Harkins described the technique of partial gastric vagotomy in dogs, interrupting those vagal fibers that supply the acidpepsin secreting fundus and corpus of the stomach but saving the fibers to the antropyloric complex (Fig. 1). 19 This procedure eliminated the cephalic phase of gastric secretion but did not interfere appreciably with gastric emptying. Holle and Hart first reported the use of parietal cell vagotomy in humans but added a drainage procedure negating, in part, the advantages of this type of vagotomy. 21 Amdrup and Jensen 2 and Johnston and Wilkinson 29 also carried out this procedure in humans but preserved the integrity of the pylorus. '''Department of Surgery, Lahey Clinic Foundation, Boston, Massachusetts
Surgical Clinics of North America- Vol. 60, No.2, April 1980
247
~o .. ~. ''''"·•"""·" . - .
248
RICARDO
Figure 1.
L.
RosSI AND jOHN
W.
BRAASCH
Types of vagotomy: a, truncal; b, selective; and c, highly selective parietal cell
vagotomy.
It has been postulated31 that the potential advantages of parietal cell vagotomy include low operative mortality and morbidity, an innervated pylorus and antrum that may provide nearly normal gastric emptying, possible preservation of inhibitory effects on acid secretion by the intact extragastric and antral branches of the vagus nerves, maintenance of a functioning pylorus, which may reduce duodenal reflux into the stomach, and preservation of duodenal innervation without interfering with the normal release of duodenal hormones.
ANATOMY OF VAGUS NERVES The left vagus nerve (Fig. 2) continues anteriorly in the lesser omentum parallel to the lesser curvature of the stomach at about 1 to 2 em from it, forming the anterior nerve of Latarjet. 19• 36 It reaches the pyloric antral area where it fans out into branches forming the "crow's foot" that is generally within 7 em of the pyloroduodenal junction. The anterior vagus nerve supplies the hepatic branch to the gallbladder and biliary tree.
249
pARIETAL CELL VAGOTOMY
_..~Anterior
vagal n.
Hepatic br.
Ant. nerve of Latarjet
Figure 2.
Anatomy of the anterior vagus nerve.
The right vagus nerve (Fig. 3) continues in the posterior aspect of the lesser omentum, formi:rig the posterior nerve of Latarjet and having a position similar to that of the anterior nerve. Early in its course, a branch to the celiac plexus supplies vagal fibers to the bowel and other abdominal viscera.
SURGICAL TECHNIQUES We use a modification of the technique described by Goligher.' 3 Exposure of the proximal stomach and distal esophagus is critical in the performance of this operation. A midline incision extends from along the xiphoid process to the umbilicus. The falciform ligament is divided and ligated, and the abdomen is explored. The bladder blade of a Balfour retractor is placed substernally and tied over the ether screen to the operating table by the anesthesiologist with a sterile, double-fold strip of cloth or gauze, thereby increasing access to the upper abdominal and subdiaphragmatic space (Fig. 4). A regular Balfour retractor is used in the lower half of the incision. The operating table is placed in the reverse Trendelenburg position of approximately 15 to 20 degrees to give countertraction to the substernal retractor and to allow the abdominal contents to descend.
r 250
RICARDO
L.
ROSSI AND ]OHN
...-Celiac br. /
-----Post. nerve _---of Latarjet
Grow's foot / /
/
Figure 3.
Anatomy of the posterior vagus nerve.
W.
BRAASCH
r
pARIETAL CELL VAGOTOMY
251
Figure 4. The bladder blade of a Balfour retractor is placed substernally and tied over the ether screen to the operating table.
The anterior nerve of Latarjet and the hepatic branch of the anterior vagus nerve are identified. The gastrohepatic ligament is opened without damaging these structures to allow for retraction of the lesser omentum by the left hand of the operating surgeon (Fig. 5A). The first assistant retracts the stomach with the left hand by grasping a large intragastric tube. We do not routinely incise the triangular ligament of the left lobe of the liver or isolate the main vagus trunks at this stage, although this may be a useful technique for surgeons who are beginning to use this procedure. When the craw's foot is identified, dissection of the anterior leaf of the gastrohepatic ligament is begun not closer than 7 em from the pylorus (Fig. 5B). Dissection is carried out close to the stomach to avoid injury to the nerve of Latarj et. Each vessel with its accompanying nerve branch is ligated in continuity on the omental side and is clamped on the stomach side (Fig. 6). The vessels and nerve branches are thereafter transected and ligated on the stomach side (Fig. 7). We avoid the temptation of using coagulation or clips because of frequent bleeding associated with these hemostatic procedures. The dissection is contin-
r
\lklldli.IOJII.II~ ...........iioillliiii--IO-IIC'"'"--""''""""'"
I, II
252
RICARDO
L.
RoSSI AND joHN
W.
BRAASCH
Figure 5. A, Exposure of lesser curvature of stomach and nerve of Latarjet. Surgeon's left hand retracts gastrohepatic ligament while the first assistant retracts the stomach by grasping the nasogastric tube. B, Dissection of the anterior leaf of gastrohepatic ligament is begun at the left of the crow 1s foot approximately 7 em from the pylorus.
pARIETAL CELL VAGOTOMY
253
Figure 6. Dissection is accomplished close to the stomach. A, Each vessel is ligated in continuity at the side of the left gastric artery and (B) clamped on the stomach side.
ued cephalad toward the gastroesophageal area (Fig. SA). When dissection allows easy visibility of the posterior leaf of the gastrohepatic ligament, its vessels can be clamped and transected using the same precautions as with the anterior leaf (Fig. 8B ). The lesser sac is entered. A Penrose drain placed in the rent of the gastrohepatic ligament aids in its retraction for better exposure of its vessel and nerve fibers thereby avoiding injury to the nerve of Latarjet. The dissection is continued toward the angle of His. Frequently, a fat pad overlying the gastroesophageal area indicates the line of dissection (see Fig. 8B). The dissection is continued around the esophagus; the
Figure 7.
A and B, Vessels are transected and ligated on the stomach side.
254
RICARDO
L.
Rossi AND]OHN
W.
BRAASCH
Figure 8. A, Dissection is carried out close to the stomach and extended cephalad toward the gastroesophageal area, exposing the posterior leaf of the gastrohepatic ligament. B, Posterior leaf of the gastrohepatic ligament is divided, and the lesser sac is entered. Dissection is continued toward the angle of His. C, Dissection of the lower esophagus is begun and extended to the first short gastric vessel.
pARIETAL CELL VAGOTOMY
255
Figure 8 Continued. D, Esophagus is retracted, and the posterior vagal branches are transected. E, Esophageal dissection is extended cephalad for 5 to 7 em from the gastroesophageal junction.
256
RICARDO
L.
Rossr AND joHN
W.
BRAASCH
lesser omentum is always retracted toward the right to avoid injury to the main vagal trunks. The greater curvature is dissected up from the esophagus to the first short gastric vessel (Fig. 8C). At this stage, the esophagus is retracted anteriorly, and any branches found in the posterior wall of the esophagus and esophagogastric junction are dissected and transected (Fig. 8D). The esophagus is dissected for 5 to 7 em, isolating it completely from the vagal branches (Fig. 8E). Once hemostasis is insured, the extent of vagal denervation is reassessed. The distance between the pylorus and the site of dissection in the lesser curvature is measured to make sure that the posterior leaf of the lesser omentum has been divided to the same extent as has the anterior leaf. We do not routinely open the gastrocolic ligament in our operation, but this can be performed either for dissection of the posterior leaf of the lesser omentum or to assess the extent and adequacy of the dissection. Dissection of the distal esophagus is one of the key factors in the success of this operation. We do not include any antireflux procedure unless a specific preoperative indication is present. We do not routinely imbricate the lesser curvature of the stomach.
Pyloric Dilatation When pyloroduodenal stenosis exists, as assessed by the preoperative barium study of the upper gastrointestinal tract or endoscopy, symptoms of gastric outlet obstruction, or operative findings, dilatation is considered. For this, a longitudinal gastrostomy is performed near the pylorus and close to the greater curvature to avoid denervation of the antrum (Fig. 9). It is made of a size that allows the introduction of one finger. Introduction of the index finger helps to assess the extent of stenosis and the degree of fibrosis or edema. The finger is advanced gently into the duodenum. A number 18 Hegar dilator can be used. Occasionally a small tear of the duodenal wall occurs with this procedure; it should be looked for and, if found, closed in a transverse fashion.
RESULTS For a procedure to be accepted as new therapy for ulcer disease, it must be associated with some major improvement, such as a lower operative mortality and operative morbidity, a lower incidence of late side effects, or a lower recurrence rate, and it must have technically reproducible results.
Operative Mortality and Morbidity A worldwide survey of results of more than 5000 highly selective vagotomies performed electively for duodenal ulcer gave an operative mortality rate of 0.3 per cent. 28 This was lower than that found in collected series after vagotomy with drainage (0.8 per cent) or after gastric resection with or without vagotomy (more than 1 per cent) - differences that are highly significant statistically.
PARIETAL CELL VAGOTOMY
257
Figure 9. Pyloroduodenal dilatation. A, A small gastrostomy is performed close to the pylorus and to the greater curvature. B, The pyloroduodenal area is assessed by palpation. Gentle finger dilatation is performed. C, Gastrostomy is closed.
Necrosis of the lesser curvature of the stomach occurred in 0.2 per cent of patients and was responsible for death in half of them (0.1 per cent). 27 This represents a specific complication of highly selective vagotomy. Its pathogenic mechanism is unclear, but it has been thought to be related to ischemia from devascularization of the lesser curvature or from ligatures that include part of the gastric wall. A higher incidence of this complication has been reported when highly selective vagotomy is used prophylactically for duodenal ulcer in patients who are to undergo renal transplantation. 27 To avoid this complication, reperitonealization of the lesser curvature of the stomach has been recommended 8 after highly selective vagotomy, but it has not achieved widespread accept-
258
RICARDO
L.
ROSSI AND ]OHN
W.
BRAASCH
ance. Splenectomy for surgical trauma is required in less than 5 per cent of patients. 1 Esophageal perforation has also occurred. 1
Side Effects DuMPING. It is well accepted that dumping occurs rarely after this procedure, with an incidence of less than 5 per cent in most published series. 1· 15 · 17 • 23 · 38 When proximal gastric vagotomy is associated with pyloroplasty, the incidence of dumping increases greatly. 40 DIARRHEA. This side effect is not a problem with parietal cell vagotomy, having an incidence that fluctuates between 0 and 3 per cent. 1· 15· 30 Diarrhea and dumping appear to be of mild or moderate severity and to subside within two years in most patients. When comparing other side effects, such as postprandial epigastric fullness and vomiting of bile, Goligher et al. found no appreciable difference after highly selective vagotomy, truncal vagotomy, and drainage or antrectomy.15 DELAYED GASTRIC EMPTYING. Symptoms suggesting gastric stasis, such as epigastric fullness, bloating, and hiccups, occurred early in the postoperative period in 0 to 30 per cent of patients who had undergone parietal cell vagotomy.27. 38 The symptoms do not seem to be more frequent than with other ulcer operations and tend to subside in most patients by two months from the time of operation. Gastric emptying for solids is normal after this procedure, 6 • 22 but early gastric emptying of liquids has been faster 24 or unchanged. 7In patients who have undergone parietal cell vagotomy and pyloric dilatation for pyloric stenosis, symptomatic improvement occurs early, but radiographic findings of delayed gastric emptying can take as long as 12 months before complete return to normal. 10 / GASTROESOPHAGEAL REFLUX. Some surgeons suggest that since parietal cell vagotomy may be associated with a high incidence of postoperative gastroesophageal reflux, a simultaneous antireflux procedure should be added. 37· 39 Csendes demonstrated that denervation of the cardia and the lower part of the esophagus did not influence the lower gastroesophageal sphincter pressures or produce gastroesophageal reflux as determined by the pH glass electrode. 9 Therefore, it does not appear advisable to perform routine antireflux procedures in patients undergoing parietal cell vagotomy. This concurs with our experience. 5 When the presence of gastroesophageal reflux is established by careful preoperative evaluation, including manometric or acid reflux studies, an antireflux procedure would be indicated at the time of parietal cell vagotomy. Recurrence Rates and Effects of Parietal Cell Vagotomy on Gastric Acid Production In most published reports, highly selective vagotomy consistently abolishes the acid response to insulin early after operation (one week), but on serial testing at five years postoperatively, approximately 90 per cent of patients will have positive responses to insulin using Hollander's
pARIETAL CELL VAGOTOMY
259
criteria. 35 With selective vagotomy or truncal vagotomy, positive results to the Hollander test have been found in up to 50 per cent of patients. The decrease in gastric acid production is appreciable. During the first months after vagotomy, acid production progressively increases but stabilizes between one and five years postoperatively. 4 By five years, reduction in basal acid output is 80 per cent, and that of maximal acid output and peak acid output after pentagastrin is approximately 50 per cent. 18 The recurrence rate for duodenal ulcer after highly selective vagotomy is not well known, as long-term follow-up studies are necessary and only a few large series have follow-up data for more than five years. Recurrence rates vary between 4 and 10 per cent,4 • 15 but recurrence rates as high as 20 per cent have been reported. 34 In a series of II7 patients studied for five to eight years, the recurrence rate was 4.3 per cent. 15 It is estimated that the long-term recurrence rate of ulcer after parietal cell vagotomy will be similar to that found after truncal vagotomy and will approach 10 per cent. 4 Several factors appear to be related to the incidence of recurrence. Technical aspects are of importance. The degree of vagal denervation has been determined by anatomic landmarks as described by Goligher, 13 by using Congo red stain or by using an intragastric pH probe as described by Amdrup et aP and Grassi. 16 All of these techniques appear equally effective in determining the distal limit of denervation as long as dissection is begun less than 10 em from the pylorus. In contrast, proximal vagal denervation is critical. When esophageal dissection is carried only for a short distance, a high incidence of early postoperative positive results on the Hollander test and a recurrence rate of 20 per cent or more are recorded. 20 • 34 If denervation is extended 5 to 7 em proximal to the esophagogastric junction, the recurrence rate is decreased. The best result is accomplished by a dissection carried out as close to the stomach as possible, that is, started at the left of the craw's foot at approximately 7 em from the pylorus and extended proximally around the esophagus for 5 to 7 em with careful dissection of posterior esophagogastric branches. The selection of patients to undergo this operation can be important. Wastell et al. noted that recurrence rates after proximal gastric vagotomy are higher in patients who have hypersecretion with a peak acid output after pentagastrin of more than 35 mM an hour. 40 These findings have not been demonstrated in other series. 28 Some evidence indicates that the recurrence rate after proximal gastric vagotomy is higher when the procedure is used for gastric ulcer than when it is used for duodenal ulcer, 4 which brings into question the use of the operation in the former circumstance. The Hollander test and other tests for gastric acid secretion have been used to assess the success of parietal cell vagotomy. Although an early positive Hollander test (one week) has been related to a higher incidence of recurrence, 28 none of these studies has proved to help consistently in identifying the patient with a high likelihood for recurrence or as a criterion for an adequate technical procedure. 26 Ulcers
260
RICARDO
L.
ROSSI AND JOHN
W.
BRAASCH
recur both in patients with positive and those with negative responses to the Hollander test.
Overall Results Using a modification of the Visick classification, Goligher and Hill rated their five-year to eight-year results as excellent or very good (Visick I and II) in 75 per cent of patients, as fair (Visick III) in 13 per cent of patients, and as failures (Visick IV) in 12 per cent of patients. 15 Amdrup et al. 1 reported good or excellent results in 83 per cent of their patients with a follow-up review of two years, whereas Grassi 17 noted similar results in more than 90 per cent of patients. Lahey Clinic Experience At the Lahey Clinic we have reviewed, but not yet reported on, our first 53 patients who have undergone parietal cell vagotomy with a median follow-up period of 30 months (range, 12 to 57 months). The main surgical indication was intractability, although one-third of our patients had different degrees of pyloroduodenal obstruction that required dilatation. More than 80 per cent of our patients had an excellent or very good result, according to the Visick grading as modified by Goligher et al. 14 (Table 1). For patients treated for intractability, the recurrence rate was 3 per cent, but in those with preoperative gastric outlet obstruction, it was more than 10 per cent. Most of the recurrences have been controlled with medical therapy. Dumping and diarrhea were not problems, and symptoms suggestive of delayed gastric emptying resolved in all patients.
Table 1. Overall Grading of Results (Modified Visick Classification)':' CATEGORY
I. Excellent II. Very good
III. Satisfactory
IV. Unsatisfactory
DEFINITION
Absolutely no symptoms; perfect result Patient considers result perfect, but interrogation elicits mild occasional symptoms easily controlled by minor adjustment in diet Mild to moderate symptoms not controlled by care causing some discomfort, but patient and surgeon satisfied with result, which does not interfere seriously with life or work Moderate or severe symptoms or complications that interfere considerably with work or enjoyment of life; patient or physician dissatisfied with result; includes all patients with proved recurrent ulcer and those submitted to further operation, even though the latter may have been followed by considerable symptomatic improvement
*Modified by Goligher, J. C., Feather, D. B., Hall, R., et al.: Several standard elective operations for duodenal uicer: Ten to 16 year clinical results. Ann. Surg., 189:18-24, 1979.
261
pARIETAL CELL VAGOTOMY
INDICATIONS
'i , I
The primary indication for parietal cell vagotomy is in the elective management of patients with duodenal ulcer in whom the surgical indication is intractability. Highly selective vagotomy has also been performed occasionally in association with suture plication of perforated duodenal ulcers 32 in good surgical risk patients who had exploratory laparotomy soon after the perforation had occurred and had minimal findings of peritonitis. It has also been employed in association with suture ligation for a bleeding ulcer. 28 Pyloroduodenal dilatation and parietal cell vagotomy have been reported 10 in the management of patients with duodenal ulcer and gastric outlet obstruction. We must realize, though, that experience in the management of the complications of duodenal ulcer by parietal cell vagotomy is limited, patient selection is important, and in the presence of a complication this procedure should probably not be attempted except by surgeons who have had experience with this technique.
CONCLUSION Since Amdrup and Jensen 2 and Johnston and Wilkinson 29 first carried out parietal cell vagotomy with preservation of the pylorus as had been described in dogs by Griffith and Harkins, 19 important experience with this procedure has been accumulated. Although long-term followup data to assess clearly the advantages and disadvantages of this procedure have still not been obtained, it appears that the low operative mortality and morbidity and the low incidence of side effects, such as dumping and diarrhea, are withstanding the test of time. The recurrence rate increases with the length of the follow-up period, but it is estimated that it will approach that of truncal vagotomy and drainage and be in the range of 10 per cent. So far, the majority of patients who have a recurrent ulcer improve on medical therapy and only a minority require reoperation. Technical aspects appear clearly related to the incidence of ulcer recurrence. We believe good results are to be expected when the dissection is begun at the left of the crow's foot at approximately 7 em from the pylorus, is carried proximally as close to the stomach as possible, and is continued around the esophagus for a distance of 5 to 7 em, with a careful watch for the posterior branches in the esophagogastric area. Close clinical follow-up study of these patients is the best way to determine the success of the operation. Studies of gastric acid have not been able to identify consistently those patients who are at high risk of recurrence or to determine the technical adequacy of the vagotomy. When symptoms of delayed gastric emptying occur, they are mild and transient. The main indication for this procedure is intractable duodenal ulcer. The use of this procedure in the presence of perforation or active
262
RICARDO
L.
ROSSI AND jOHN
W.
BRAASCH
bleeding requires a high degree of patient selection and should be reserved for those surgeons who have important experience with parietal cell vagotomy. Parietal cell vagotomy could be less successful for gastric ulcer than for duodenal ulcer, and we cannot recommend this procedure for gastric ulcer at the present time. Although the procedure is not a technically demanding operation, its subtleties are best learned in the operating room from someone with expertise in the procedure. Patients who have undergone parietal cell vagotomy require close long-term follow-up care.
REFERENCES 1. Amdrup, E., Andersen, D., and Hl')strup, H.: The Aarhus County vagotomy trial. I. An interim report on primary results and incidence of sequelae following parietal cell vagotomy and selective gastric vagotomy in 748 patients. World J. Surg., 2:85-90, 1978. 2. Amdrup, E., and Jensen, H. E.: Selective vagotomy of the parietal cell mass preserving innervation of the undrained antrum: A preliminary report of results in patients with duodenal ulcer. Gastroenterology, 59:522-527, 1970. 3. Amdrup, E., Jensen, H. E., Johnston, D., et al.: Clinical results of parietal cell vagotomy (highly selective vagotomy) two to four years after operation. Ann. Surg., 180:279-284, 1974. 4. Andersen, D., Hl')strup, H., and Amdrup, E.: The Aarhus County vagotomy trial. II. An interim report on reduction in acid secretion and ulcer recurrence rate following parietal cell vagotomy and selective gastric vagotomy. World J. Surg., 2:91-99, 1978. 5. Braasch, J. W., Sala, L. E., Ellis, F. H., Jr., et al.: Effect of parietal cell vagotomy on lower esophageal sphincter function. Arch. Surg. (in press). 6. Brandsborg, 0., Brandsborg, M., Ll')vgreen, N. A., et al.: Influence of parietal cell vagotomy and selective gastric vagotomy on gastric emptying rate and serum gastrin concentration. Gastroenterology, 72:212-214, 1977. 7. Clarke, R. J., and Alexander-Williams, J.: The effect of preserving antral innervation and of a pyloroplasty on gastric emptying after vagotomy in man. Gut, 14:300-307, 1973. 8. Croft, R. J.: Reperitonealization and invagination of the lesser curvature of the stomach following proximal gastric vagotomy. Arch. Surg., 113:206-207, 1978. 9. Csendes, A., 0ster, M., Ml')ller, J. T., et al.: Gastroesophageal reflux in duodenal ulcer patients before and after vagotomy. Ann. Surg., 188:804-808, 1978. 10. Delaney, P.: Preoperative grading of pyloric stenosis: A long term clinical and radiological follow-up of patients with severe pyloric stenosis treated by highly selective vagotomy and dilatation of the stricture. Br. J. Surg., 65:157-160, 1978. 11. Dragstedt, L. R., and Owens, F. M., Jr.: Subdiaphragmatic section of vagus nerves in treatment of duodenal ulcer. Proc. Soc. Exp. Biol. Med., 53:152-154, 1943. 12. Franksson, C.: Selective abdominal vagotomy. Acta. Chir. Scand., 96:409-412, 1948. 13. Goligher, J. C.: A technique for highly selective (parietal cell or proximal gastric) vagotomy for duodenal ulcer. Br. J. Surg., 61:337-345, 1974. 14. Goligher, J. C., Feather, D. B., Hall, R., et al.: Several standard elective operations for duodenal ulcer: Ten to 16 year clinical results. Ann. Surg., 189:18-24, 1979. 15. Goligher, J. C., Hill, G. L., Kenny, T. E., et al.: Proximal gastric vagotomy without drainage for duodenal ulcer: Results after 5-8 years. Br. J. Surg., 65:145-151, 1978. 16. Grassi, G.: Highly selective vagotomy with intra-operative acid secretive test of completeness of vagal section. Surg. Gynecol. Obstet., 140:259-264, 1975. 17. Grassi, G., Orecchia, C., Cantarelli, I., et al.: Results of highly selective vagotomy in our experience (787 cases). Chir. Gastroenterol. 11 :51-58, 1977. 18. Greenall, M. J., Lyndon, P. J., Goligher, J. C., et al.: Long term effect of highly selective vagotomy on basal and maximal acid output in man. Gastroenterology, 68:1421-1425, 1975. 19. Griffith, C. A., and Harkins, H. N.: Partial gastric vagotomy: An experimental study. Gastroenterology, 32:96-102, 1957. 20. Hallenbeck, G. A., Gleysteen, J. J., Aldrete, J. S., et al.: Proximal gastric vagotomy: Effects of two operative techniques on clinical and gastric secretory results. Ann. Surg., 184:435-440, 1976. 21. Holle, F., and Hart, W.: Neue Wege der Chirurgie des Gastroduodenalulkus. Med. Klin., 62:410-450, 1967.
pARIETAL CELL VAGOTOMY
263
22. Howlett, P. J., Ward, A. S., and Duthie, H. L.: Gastric emptying after vagotomy. Proc. R. Soc. Med., 67:836-838, 1974. 23. Humphrey, C. S., Johnston, D., Walker, B. E., et al.: Incidence of dumping after truncal and selective vagotomy with pyloroplasty and highly selective vagotomy without drainage procedure. Br. Med. J., 3:785-788, 1972. 24. Humphrey, C. S., Wilkinson, A. R., and Johnston, D.: The correlation between the rate of gastric emptying and dumping and diarrhoea after truncal, selective, and highly selective vagotomy. Br. J. Surg., 59:309, 1972. 25. Jackson, R. G.: Anatomic study of vagus nerves with a technic of transabdominal selective gastric vagus resection. Arch. Surg., 57:333-352, 1948. 26. Jaffe, B. M.: Parietal cell vagotomy: Surgical technique, gastric acid secretion, and recurrence. Surgery, 82:284-286, 1977. 27. Johnston, D.: Operative mortality and postoperative morbidity of highly selective vagotomy. Br. Med. J.,4:545-547, 1975. 28. Johnston, D., and Goligher, J. C.: Selective, highly selective, or truncal vagotomy? In 1976-a clinical appraisal. SURG. CLIN. NORTH AM., 56:1313-1334. 1976. 29. Johnston, D., Wilkinson, A. R.: Highly selective vagotomy without a drainage procedure in the treatment of duodenal ulcer. Br. J. Surg., 57:289-296, 1970. 30. Jordan, P. H., Jr.: A prospective study of parietal cell vagotomy and selective vagotomy- antrectomy for treatment of duodenal ulcer. Ann. Surg., 183:619-626, 1976. 31. Jordan, P. H., Jr.: Current status of parietal cell vagotomy. Ann. Surg., 184:659-671, 1976. 32. Jordan, P. H., Jr., and Korompi, F. L.: Evolvement of new treatment for perforated duodenal ulcer. Surg. Gynecol. Obstet., 142:391-395, 1976. 33. Latarjet, A.: Resection of nerves of stomach. Bull. Acad. de Med.,87:681-691, 1922. 34. Liedberg, G., and Oscarson, J.: Selective proximal vagotomy: Short time follow-up of 80 patients. Abstract. Scand. J. Gastroenterol., 8(Suppl20):12, 1973. 35. Lyndon, P. J., Greenan, M. J., Smith, R. B., et al.: Serial insulin tests over a five-year period after highly selective vagotomy for duodenal ulcer. Gastroenterology, 69:11881195, 1975. 36. McCrea, E. D.: The abdominal distribution of the vagus. J. Anat., 59: 1S-40, 1924. 37. Sankar, M. Y., Old, J. M., Trinder, P., et al.: The advantages of combining posterior gastropexy with proximal gastric vagotomy. Chir, Gastroenterol., 10:389-392, 1976. 38. Sawyers, J. L., Herrington, J. L., and Burney, D. P.: Proximal gastric vagotomy compared with vagotomy and antrectomy and selective gastric vagotomy and pyloroplasty. Ann. Surg., 186:510-515, 1977. 39. Temple, J. G., and McFarland, J.: Castro-oesophageal reflux complicating highly selective vagotomy. Br. Med. J., 2:168-169, 1975. 40. Wastell, C., Colin, J., Wilson, T., et al.: Prospectively randomised trial of proximal gastric vagotomy either with or without pyloroplasty in treatment of uncomplicated duodenal ulcer. Br. Med. J., 2:851-853, 1977. Lahey Clinic Foundation 605 Commonwealth Avenue Boston, Massachusetts 02215