Selecting the Vagotomy or Selecting the Patient?

149

much

depends

on

physicians’

criteria for

patients. Can a man of 60 with woken every night by severe pain,

referring

20-year history, be compared with a

of 30 with duodenitis on gastroscopy ? AMDRUP et al.2 excluded from H.s.v. any patients who had clinical symptoms of obstruction or food remnants in fasting aspirate. With the increasing recognition of antral G-cell hyperplasia there may be a group of patients who will have recurrent ulcers unless the antrum is removed; they are unlikely to be diagnosed preoperatively unless routine gastrin assays are performed. For most duodenal-ulcer patients, however, the gastrin response to food after vagotomy does not depend to any great extent on whether or not the antrum is innervated.9 AMDRUP2 and GRASSI3 denervate the parietal-cell mass precisely by plotting its extent with a pH probe, whereas most other surgeons work proximally from an arbitrary point between 6 cm. and 10 cm. from the pylorus. The antrum/body junction varies in position from patient to patient, and the 90% positive insulin test at 2 years is a little worrying. Whatever the merits of an intraoperative test for completeness of the vagotomy it may turn out to be important to ensure that the anatomical extent of the vagotomy is adequate. However, the overall reduction in basal and "maximal" acid output seems as great with H.s.v. as with other forms of vagotomy.55 As to its third aim-of reducing side-effects-there is little doubt that H.s.v. does cause less dumping, diarrhoea, and bilious vomiting than truncal or selective vagotomy with drainage. It is probably the drainage procedure as much as the vagotomy that is responsible for complications, and a pyloroplasty can be omitted with an H.S.V. provided there is no stenosis; bm scarring takes place as an ulcer heals and pyloric stenosis has occurred some time after H.S.Y. Forcibly dilating the pylorus could lead to worse scarring, but a small duodenoplasty is perfectly adequate if the scarring is away from the pylorus. If the pyloric mechanism is already destroyed by fibrosis, the surgeon need have few qualms about doing a drainage procedure.1,3 Gastric emptying after H.s.v., as would be expected, is nearer normal than after other gastric operations, especially for solids. The key problem is whether, in reducing the side-effects successfully, H.s.v. carries a high risk of recurrence. The next 5 years should answer that question. This operation is also being used for gastric ulcer. JOHNSTON 10 excises the ulcer at the same time whereas BURGE il prefers to wait for the ulcer to heal first: both these approaches eliminate the risk of leaving a malignant ulcer. However, in any moderate-sized active gastric ulcer, with the lesser omentum and nerves of Latarget involved in dense scar tissue and oedema, the operation is extremely difficult and not

a woman

Selecting the Vagotomy

or

Selecting

the Patient? THE aim of all surgery for chronic duodenal ulcer is to cure the ulcer safely and permanently with a minimum of side-effects. The surgeon should leave the stomach and duodenum as " normal " as possible while removing their ability to form ulcers. Sometimes these two aims confict. The advent of highly selective vagotomy without drainage (H.s.v.) (alias parietal-cell vagotomy, selective proximal vagotomy,l1 or proximal gastric vagotomy) is entirely rational; it is the end-stage of a logical progression. Why denervate the whole of the stomach when the aim is to reduce acid secretion ? Why destroy or bypass the beautifully coordinated antro-pyloro-duodenal mechanism by pyloroplasty or gastroenterostomy, if this is not necessary ? Thanks to the work of a number of 2-6 we are now in the surgeons in different countries position to assess the clinical results of H.s.v. over the past five years. It is a safe operation. According to JOHNSTON,s over a thousand have been reported across the world without an operative death, though lately there have been one or two alarming reportsof sloughing of the lesser curvature of the stomach which should make the surgeon scrupulous with his technique and perhaps wary of using diathermy in this area. Does H.s.v. cure the ulcer permanently ? It is too early to be certain, but the results up to 5 years are promising. In the Leeds/Copenhagen series there have so far been no proven recurrent duodenal ulcers, although 3% were suspected clinically of having a recurrence; two patients acquired gastric ulcers.2 There have been reports from other hospitals of recurrences in up to 20% within 18 months, but these may have

been partly attributable

inadequate technique at that time.Although the operation is more difficult than selective vagotomy it is certainly not beyond the skill of most general surgeons. The great difficulty in comparing any studies from different hospitals and from different countries is that few details are usually given about preoperative symptoms and methods of selection for operation. to

We are often told that the series is consecutive, but 1. 2.

Holle, F., Hart, W. Medsche Klin. 1967, 62, 441. Amdrup, E., Jensen, H. E., Johnston, D., Walker, B. E., Goligher, J. C. Ann. Surg. 1974, 180, 279. 3. Grassi, G. Proceedings of 18th Congress, International College of Surgeons; p. 677. 1972. 4. Hedenstedt, S., Lundquist, G., Moberg, S. Acta chir. scand. 1972, 138, 591. 5. Johnston, D. Gut, 1974, 15, 748. 6. Kennedy, T. Westminster Hospital Symposium on Chronic Duodenal Ulcer; p. 213. London, 1974. 7. Newcombe, J. F. Br. med. J. 1973, i, 610. 8. Liedberg, G., Oscarson, J. Scand. J. Gastroent. 1973, 8, suppl. 20, p. 12.

9.

Stadil, F., Rehfeld, J. F., Christiansen, P. M., Kronberg, O. Br. J. Surg. 1974, 61, 884. 10. Johnston, D., Lyndron, P. J., Smith, R. B. Gut, 1973, 14, 825. 11. Amery, A. H., Cox, P., Burge, H. Chir. Gastroent. 1974, 8, 11.

150

without like

ask what the ulcers are the indications preoperatively for operation in these gastric-ulcer patients if the operation can be done with relative ease. Now the practical question is, should H.s.v. without drainage become the standard operation for chronic duodenal ulcer ? On existing evidence the operation is justifiable provided the surgeon is prepared to follow patients carefully and assess the results objectively. It is too early to promote H.s.v. as the ideal operation for duodenal-ulcer disease. One danger of a new and fashionable operation is that it will be used by enthusiasts in unsuitable situations-for example, in a patient with an acute bleed, whose immediate need is for a quick operation and adequate undersewing of the bleeding-point. In any future trials and reports it would be so helpful to know the state of the patient’s symptoms and ulcer before, as well as after, operation 12; perhaps a number have such mild symptoms that they are " Visick grade II " before we start treating them.

danger. Again

are

we must

and what

A Proliferation of Professors THE Professor of Medicine lived for some 900 years, from his birth in Salerno 13 to 1970, when his impending death was proclaimed from St. Mary’s. 14 The recent increase in his progeny, however, bears witness to an impressive virility in his dotage. In 1954 there were 30 professors of medicine,15 or related clinical disciplines including therapeutics and materia medica, in the non-metropolitan British universities, who shared responsibility for producing a total of over 1200 graduates each year.16 In 1964 these schools still had only 31 such chairs, 17 but by 1974 this had risen to 7718 with just over 1450 graduates. 18 Chairs of administrative medicine, cancer studies, cardiology, clinical endocrinology, clinical pharmacology, gastroenterology, geriatrics, haematology, human genetics, infectious diseases, metabolic medicine, neurology, renal medicine, rheumatology, and postgraduate medical education 17 now grace these schools, along with additional chairs of medicine. In one university up to 9 such professors produce 190 graduates per year, whereas in another 1 professor alone bears responsibility for 130 graduates. 19 This disparity may reflect that rich variety of custom for which our island is famous, but nonetheless leads to legitimate curiosity as to how such differing patterns produce the same result. Or do they ? This increase in the medical professoriate, doubling the professor/student ratio over the past 10-20 years, Philip, A. E., Small, W. P., Neilson, J., Henderson, M. A. Lancet, Jan. 4, 1975, p. 29. 13. Payne, J. F. Encyclopaedia Britannica; vol. XVIII, p. 46. Cambridge, 12. Cay, E. L.,

1911. 14. Peart, W. S. Lancet, 1970, i, 401. 15. World of Learning: Europa. London, 1954. 16. University Grants Committee, 1974. Unpublished. 17. World of Learning: Europa. London, 1964. 18. World of Learning: Europa. London, 1974. 19. Commonwealth Universities Year Book. London, 1974.

lead an uncharitable and ignorant Martian t( suggest that inflation on Earth is not limited t( monetary matters alone. An informed Earthlin would realise that professorial responsibilities corn bine practice and research 20 in addition to under.

might

graduate teaching. However, the function of th< professor has probably changed over these years with potential, if not yet actual, separation of hi administrative role as head of department from th( professorial title awarded for his distinction ir academic matters. This separation seems essential for

spare our students from the extrem( overcrowding of their clinical curricula which woulc result if each professor insisted that his status demanded equality of teaching-time with that of all hi professorial peers. Chairmanship of a multi-professorial department although still rare in Britain, is common in Nom America, where plurality of professors is more firmly established. Thus in 1972 McGill University had 9 chairs of medicine and 12 of experimental medicine: with 126 medical graduates,19 and even in 1964 the University of Pennsylvania had 21 such chairs." As CHRISTIE 21 says, the chairman of such a department of medicine has the authority to control appointments, duties, and policies for a limited period only, without that security of tenure over these powers which is at present enjoyed by the British professor. The possibility that he might not be reappointed to office, if those governed think that he has misused his powers, is held to be a potentially important constraint on the chairman. 21 It is interesting that this lack of security in an office which carries authority over others is found in some higher academic posts in Britain, such as the deanship of a faculty. Again, the burden of chairmanship, like that of deanship, will usually prevent continued active participation in either practice or research-another important reason for limiting tenure of office. Who are the department ? The Todd Report 22 suggested that all clinical teaching in a discipline should be " under the direction of one academic head ". Whilst recognising the contrast between the full-time academic, with honorary consultant status, but accustomed to hierarchical university rule, and the relatively autonomous N.H.S. consultant, either full-time or part-time, Todd could only hope that their responsibility in academic government would be related to their contribution to academic affairs. Strong feelings continue to motivate these differences, as revealed in the current debate on professional contracts, but it seems possible that reasonable men may yet find common ground, we must

perhaps

as

first in the

teaching-hospital consultants-maybe at Scottish schools, with their longer tradi-

20. Donald, K. W. Proc. R. Soc. Med. 1971, 64, 303. 21. Christie, R. V. Br. med. J. 1969, iv, 385. 22. Report of the Royal Commission on Medical Education. H.M. Stationery Office, 1968.