The surgical treatment of duodenal ulcer by vagotomy and antral resection

The

Surgical Treatment of Duodenal Ulcer By Vagotomy and Antral Resection

LEONARDW. EDWARDS,M.D., WILLIAM H. EDWARDS, M.D., JOHN L. SAWYERS, M.D., WALTER G. GOBBEL, JR., M.D., J. LYNWOOD HERRINGTON, JR., M.D. AND H. WILLIAM SCOTT, JR., M.D., Nashdle, Tennessee

From tbe Department of Surgery, Vanderbilt University School of Medicine. tbe Edwards-Eve Clinic. tbe Sureical Services * oj Vandkrbilt University Hospkal, Tbiyer Veterans Administration Hospital and Nashville Gerleral Hospital, Nashville, Tennessee.

HE ADVENT of a physiologic and anatomic approach to the surgical treatment of the complications of duodenal ulcer has afforded an opportunity for the clinical evaluation of a large series of patients foIIowed-up for an adequate number of years. Within the past decade, three surgica1 procedures have been widely utilized in the surgical treatment of duodena1 uIcer. These are vagotomy and antra1 resection, vagotomy with a drainage procedure and “adequate” subtota1 gastric resection. AI1 these operations are designed to ehminate the uIcer diathesis; and when competently performed, tend to reduce excessive acid peptic secretions to norma or subnormal levels. UntiI recentIy, the most widely used procedure has been the so-caIIed “adequate” subtotal gastric resection which entaiIs a 70 to 80 per cent resection of the distaI stomach without vagotomy. This method eIiminates the antra1 phase of gastric secretion, reduces the parietal ceI1 mass, but has the disadvantage of Ieaving a smaI1 gastric reservoir and not controhing the cephalic phase of secretion. These disadvantages along with the high operative mortality rate and the high recurrence rate have led us to believe that this procedure should be abandoned in the modern surgical treatment for duodenal ulcer. Smithwick [I] has recently noted a mortality rate of 3.4 per cent and a recurrence rate of 6.1 per cent in 530 patients who had adequate subtotal gastric resection with a fifteen year follow-up period. Marshall 121 from the Lahey

T

American

Journal

of Surgery,

Volume

107,

March

1963

352

CIinic has reported a recurrence rate of 4 per cent in a series of over 2,000 patients. Woodward’s [?J 9.1 per cent rate of marginal ulceration lends further support to our belief regarding this operative procedure. The most significant contribution to the surgica1 treatment of duodenal ulcer has been the reintroduction of vagotomy by Dragstedt [a], AIthough vagotomy alone has not withstood the test of time, vagotomy accompanied by resection of the gastric antrum and vagotomy accompanied by a drainage procedure have rapidIy gained favor with the majority of surgeons in the treatment of duodenal ulcer. Vagotomy with gastrojejunostomy has the advantages of maintaining a large gastric reservoir, eIiminating the cephalic phase of gastric secretion and being a technically simple operation accompanied by a low mortality rate. However, there are disadvantages in that the antral phase of gastric secretion is not controlled, bIeeding uIcers are inadequateIy treated and recurrence rate is too high. Dragstedt [i;] has reported a recurrence rate of 10.6 per cent among a group of 724 patients. A review of our own series of vagotomy and gastroenterostomies reveaI a 13.3 per cent recurrence rate in 147 patients [6]. Waiters and MobIey [7] reported a. simiIar uIcer recurrence rate of 13 per cent from the Mayo Clinic. Vagotomy combined with pyloroplasty has the same advantages as mentioned for vagotomy with gastrojejunostomy. The disadvantages include failure of control of the antral phase of gastric secretion and a relatively high recurrence rate. The procedure does permit control of the bleeding ulcer by suture ligation. Weinberg [8] has a series of over 1,000 patients

Vagotomy

and AntraI

treated by vagotomy and pyIoropIasty with an enviable mortality rate of 0.7 per cent, but an uIcer recurrence rate of 5 per cent. Farris [9] reports a 2 per cent mortaIity rate in a series of 2 IO patients ; Smithwick’s [I] figures indicate a 5.5 per cent mortality rate in a series of Iess than IOO patients. In 1946 vagotomy was combined with resection of the dista1 stomach (hemigastrectomy) Smithwick and Farmer [IO]. Several months later Edwards and Herrington [I I] started the present series by a simiIar procedure, termed “antrectomy.” This operation is based on the sound physiologic concept of eliminating both cephalic and gastric phases of acid secretion; 50 to 60 per cent of the gastric reservoir is maintained. It permits definitive treatment in al1 the usua1 presenting forms of duodenal uIcer, including the compIications of bIeeding, obstruction and perforation. OPERATIVE

TECHNIC

The surgica1 procedure consists of a meticuIousIy performed biIatera1 subdiaphragmatic vagotomy with a resection of the distaI 40 per cent of the stomach. The technic of vagotomy described by one of us (L. W. E.) has been used in the patients comprising this series [ 121. The abdomen is entered through an upper mid-line or left paramedian incision, made as cephaIad as possible to the Ieft of the ensiform cartiIage. Retractors are placed under each costal margin to aid in exposure. View of the esophagea1 hiatus is facilitated by division of the coronary Iigament of the left Iobe of the liver and its retraction to the right, protected by a moist Mikulicz pad. Division and reflection of the left Iiver Iobe is superior to attempting to work beneath this Iobe of the Iiver as advocated by some surgeons. In this series of patients, not a singIe complication has deveIoped as a resuIt of this maneuver. Improper traction aIong the greater curvature of the stomach wiI1 occasionaIIy lead to tears in the spIenic capsule, but this is in no way related to retraction of the Iiver. Exposure of the esophagus is then compIeted by incising the overIying peritoneum, and with the aid of an indweIIing Levine tube for identification, the esophagus is delivered from the mediastinum by gentle, bIunt dissection with the operator’s right index finger and thumb. This allows the esophagus to be retracted downward 4 to 5 cm., 353

Resection

and pIaces the vagus nerves under tension. The norma anatomic rotation of vagal fibers pIaces the right nerve trunk posterior to the esophagus, and at times severa millimeters from the muscuIature of the esophagus so that this nerve often lies on the anterior surface of the aorta. The Ieft nerve is generaIIy smaIIer than the right and is usuaIIy Iocated on the anterior waI1, sIightIy embedded in the esophageaI musculature. After identification and division of these two major trunks, a11 fibers which resembIe nerves are similarIy divided, insuring an adequate vagotomy. FolIowing vagotomy, the gastric antrum is excised. Alimentary reconstruction was accompIished by one of the BiIIroth II types of gastrojejunostomy in the earlier part of the series; however, in the past seven or eight years, end to end gastroduodenostomy of the Schoemaker-Billroth I type has been the anastomotic procedure of choice. There has always been some question regarding just how much of the stomach constitutes the pyloric antrum and how extensive a resection should be performed. Landboe-Christensen [rj] of Copenhagen in studying forty-seven human stomach specimens removed from patients in various age groups was able to demonstrate a sharp microscopic transition between the pyloric fundic gland areas in the majority of patients by empIoying a water acetic acid-cIearing technic. His conclusions were that the pyIoric antral zone occupied a greater length on the lesser than on the greater curvature. His measurements and calculations depicting the extent of the antra1 segment has demonstrated that this portion of the stomach occupied approximateIy 44 per cent of the Iength of the Iesser curvature and approximately 12 per cent of the distal extent of the greater curvature. The cIinica1 application of these findings has resulted in our selecting on the Iesser curvature side a site for division of the stomach just proxima1 to the point midway between the gastroesophageal junction and the pyIoric vein. This site of division is usually Iocated 2 to 4 cm. proximal to the incisura anguIaris. A similar midway point on the greater curvature of the stomach is seIected. The stomach is divided between two straight Kocher clamps placed at right angles to the long axis of the stomach along the greater curvature at the point selected. This portion of the stomach is then divided. The cIamps are pIaced from

Edwards,

Edwards,

Sawyers,

GobbeI,

this point of division in an obIique manner to the Iesser curvature up to the point seIected for division. This removes the tongue of antral tissue that tends to extend higher on the lesser curvature of the stomach. The relative extent of this type of gastrectomy represents about a 40 per cent resection in terms of tota mucosa1 surface area. Slightly more than the antra1 segment is removed, but it shouId be stressed that the proxima1 extent of the antra1 glands does not terminate in an abrupt transition, but graduaIIy bIends with the more proxima1 gIands of the fundus. Resection of sIightIy more than the antra1 segment insures the operator of compIete antra1 extrapation, but the extent of the gastrectomy does not unduty sacrifice the function of the stomach as a storage organ [14]. The hazards of retained antral tissue have been previously pointed out by the authors [IS]. CLINICAL

Herrington

and Scott

the duodena1 ulcer, but a vagotomy and antral resection were performed without dificulty. His weight gain and development have been normal. No evidence of postoperative anemia or nutritional deficits have fleen noted. The indications for operation in this group are listed in Figure I. Except for a few patients who had acute massive bleeding or acute perforation as the first manifestation of ufcer disease, operation was performed for chronic duodenal ulcer and its complications. The duration of ulcer-like symptoms have ranged up to forty years with an average of eleven years. Pain refractory to medical management constituted the most common indication for surgicaI intervention, namely 53 per cent. Massive or recurrent hemorrhage was the principal reason for operation in 339 patients or 30 per cent. One hundred forty-four patients had pyIoric obstruction that required surgica1 intervention and thirty patients were submitted to vagotomy and antrectomy at the time of acute perforation of the duodenal ulcer. Among the 1,127 patients subjected tv operation, $79 had a Billroth I (gastroduodenostomy) anastomosis and 548 had a Billroth II (gastrojejunostomy) type of reconstruction. Mortality rate in this series was 2.7 per cent. Thirty-one patients died in the hospital. Among the hospital deaths, nineteen or 61 per cent occurred in patients subjected to emergency operation for control of massive bIeeding. The majority of these patients were in the geriatric age group and were considered to be poor surgical risks when first observed. Complications from cardiovascular renaI disease in the early postoperative period accounted for twenty-one deaths in this group. Duodenal stump or anastomotic leak was responsibIe for the death in eight patients. Acute hemorrhagic pancreatitis accounted for one death, and one patient who had psuedohemophilia died from uncontrolIed postoperative hemorrhage despite massive transfusions and subsequent emergency tota gastrectomy. If the patients who died after emergency operations from bleeding uIcers are excluded, the mortality rate is reduced to I. I per cent. This represents the true risk rate of patients subjected to eIective operation for the control of duodenal ulcer in this series. CompIications encountered in this group of patients following operation were those that one would find in any Iarge series of patients

MATERIAL

During a fifteen year period from January 1947, a tota of 1,127 patients have undergone vagotomy and antra1 resection for duodena1 uIcer. This group includes both private and staff patients operated on by members of the surgica1 service of the Vanderbilt University A%Jiated Hospitals. The patients have been obtained from Vanderbilt University Hospital, Thayer Veterans Administration Hospital, NashviIIe Genera1 HospitaI and private patients from the Edwards-Eve Clinic. AI1 patients were treated by subdiaphragmatic vagotomy accompanied by a 35 to ~5 per cent dista1 gastrectomy, sufficient to excise the antrum. Patients with more than 55 to 60 per cent resection of the stomach with vagotomy have not been included in this study. The age range has been from eight to eighty-one years with an average of about forty-six years. The series consists of 931 male and rg6 femaIe patients, with a ratio of five to one. Of considerabIe interest to us, has been the eight year old patient. This boy had been folIowed-up by the same pediatrician for several years with symptoms referabIe to the gastrointestinal tract. At age five years, a duodena1 uIcer was proved by roentgenograms; and on two occasions, the patient had required transfusions for gastrointestina1 bIeeding. Because of persistence of symptoms, surgica1 intervention was proposed. There was extensive scarring and inflammatory change around 354

Vagotomy

and AntraI

INDICATION

PAIN

FOR

Resection

OPERATION

HEMORRHAGE

- 53%

OBSTRUCTION

- 30% (339)

(614)

PERFORATION

- 13% (144) FIG

I.

- 4% (30)

Indications

undergoing surgery in the upper part of the abdomen: namely, wound infections, thrombophlebitis, pulmonary emboIus and myocardial infarction. Certain problems specifically reIated to gastric surgery were aIso encountered. Delayed emptying was noted in fifty-three patients and reoperation was necessary in fourteen. No principa1 difference was noted between the BilIroth I and Bithoth II types of reconstruction in regards to the incidence of this complication. Leakage from the duodenal stump occurred in twelve patients and four patients had leaks at site of anastomosis. RESULTS

It has been possibIe through follow-up study to assess the status of 1,073 individuals or 99 per cent of those patients who have successfuIIy undergone vagotomy and antral resections since January 1947. As previousIy mentioned, thirty-one patients died in the hospita1 patients following operation. Twenty-three have been Iost to fohow-up study since discharge. Patients who have subsequentIy died of causes unreIated to duodena1 uIcer disease 355

for operation.

(forty-one in this series) were folIowed-up to the date of their death. It has been possibIe in the great majority of instances to examine and interview these patients personally at periodic intervaIs in the offrce or dispensary, either by us or by the surgica1 residents of the Vanderbilt University AffrIiated HospitaIs. In those incidences in which a recent personal interview and examination could not be accomphshed, the patient’s current status has been obtained through contact with the referring physician or with the patient by Ietter and questionnaire. The years of foIlow-up study are shown in Figure 2. A critica appraisa1 has been made of the over-ah cIinica1 resuIts obtained from these patients. Each patient has been graded either exceIIent, good, fair or poor, depending on the following criteria: An excehent cIinica1 result indicates that the patient has no symptoms referabIe to the gastrointestinar tract. These patients have no dietary restrictions and are norma healthy persons with properIy functioning gastrointestina1 tracts. The good resuIt category incIudes patients who have exceIIent

Edwards, Edwards, Sawyers, GobbeI, Herrington and Scott LENGTH 1073

OF FOLLOW-UP PATIENTS

YEARS

FOLLOW-UP

FIG. 2. Length of foIIow-up study.

gastrointestina1 functioning, but who have occasionaIIy experienced epigastric fuIIness after meals, miId dumping and miId diarrhea; these patients are not on any medication and are unrestricted in their activity. Patients in both the good and excelIent groups are judged to have entirely satisfactory results from their operative procedures. Those patients cIassified as having had a fair resuIt have a11 received benefit from the operative procedure without residua1 ulcer symptoms, but abdomina1 fuIIness, diarrhea or moderate dumping symptoms have been prominent postoperative sequeIae. The poor resuIt category consists of patients with recurrent uIcer and those with postgastrectomy symptoms or nutritiona dificuities of such severity as to prohibit them

1073

from pursuing a IiveIihood. The over-a11 resuIts are seen in Figure 3. The exceIIent group comprised 726 patients; 278 patients were cIassified as having had good resuIts. Therefore, 93.4 per cent of the patients were judged as having satisfactory resuIts from the operation. Fifty-eight patients were classed as fair results and eIeven as poor. This latter category incIudes seven patients with recurrent uIcers. No significant difference was noted in the resuIts as tabuIated according to the type of gastrointestina1 anastomosis. Ninety-four per cent of those patients with BiIIroth II operation were simiIarIy classified. (Fig. 4.) PostprandiaI symptoms characteristic of the dumping syndrome were experienced by 274 patients or 25.5 per cent of the tota group. these symptoms were In many instances, eIicited onIy by carefu1 questioning of the patient. Symptoms have been listed as either miId, moderate or severe. Symptoms graded as mild have not been a source of distress for the patient and 77 per cent of the patients who had dumping were in the miId category. Symptoms graded as moderate have been for the most part controIIed by dietary and instructive measures. Twenty per cent of the patients with dumping were cIassified in this group. When dumping symptoms were graded and the as severe, they were incapacitating

PATIENTS

”

EXCELLENT

GOOD

FAIR

POOR

FIG. 3. ResuIts.

356

Vagotomy RESULTS

and AntraI

Resection

ACCORDING

TO TYPE

GASTROINTESTINAL %

69%

TO-

(388)

x 60 _

50

-

40

-

OF

ANASTOMOSIS

66% (3381

m

BILLROTH

I

m

BILLROTH

IX (51 I)

(562)

.:..:. ::/:j::.: Yx:, :: j/iii(:ii .::.:::i .jj:‘/i:: ::,:::::: ,,:y.::: ;j:/,;:/ 22; :,:,:“:j ::j..:,. .:jj .::::.. ji:j;:(j ..:,,::.:

FIG. 4. Results according to type of gastrointestinal

RECURRENT 7 RECURRENCES

ULCERATION

AMONG

(INCIDENCE

2 PATIENTS

POSSIBLE INCOMPLETE VAGOTOMY

1073

PATIENTS

OF 0.6%)

1 PATIENT

4 PATIENTS

MALIGNANT ZOLLINGER-ELLISON ISLET ADENOMA

FIG. 5. Recurrent u&ration. dence of 0.6 per cent.

anastomosis.

Seven recurrences

PROVEO INCOMPLETE VAGOTOMY

among 1,073 patients,

an inci-

this. Of this group, 733 patients or 76 per cent have maintained their idea1 weight as determined by standard height, weight and age charts. One hundred thirty-two patients (13 per cent) have lost IO per cent or more of their ideal weight folIowing operation. It shouId also

symptoms were not controIIed by dietary measures. There were only six patients in this group. ResuIts are shown in Figure 6. An attempt has been made to determine postoperative weight status in these patients and 956 patients have had an evaluation of 347

Edwards, %

30

Edwards,

Sawyers,

DUMPING -

GobbeI,

Herrington

and Scott

SYNDROME

63

- BILLROTH

I

(562)

m

- BILLROTH

II

(5 I I )

27% (137)

24% 25

-

(137) .::...: .::...::: 20%

20%

:. :...Y :: :ti:./: : .:;.:i :.

.:. ,:-:,:: 15

-

IO

-

5 -

:i;;;; :.:...: ..,, .. ::::: :::!::::i .... .: .f;:;;: ..? ::.1:.

.// ;: : :..: :, .: ,: .:.:. :.::I; :.:. :. : .i.. :

.:.

5%

5%

./

(271

127)

::.::.. :.:.:: ::L.. ii:..:

MILD

:. :: ../. ...

::. .-.. .: .:.i .j/ ,:i,j

MODERATE

FIG. 6. Incidence and severity of dumping syndrome, according to type of anastomosis.

with BiIIroth I type of gastroduodenostomy. Because of the patient’s poor condition at the time of reoperation, the periesophagea1 region was not explored for the possibiIity of an intact vagal fiber. Careful inspection of the pancreas failed to revea1 an adenoma, and a re-resection of the gastric pouch was performed with a Polya anastomosis. It is thought, but not proved, that this patient had an incomplete vagotomy. Her course in the ensuing five years was free of gastrointestina1 symptoms. She died suddenIy in her sleep at home a few months ago. An autopsy was not obtained. A sixth patient had a ZoIlinger-EIIison isIet ceI1 tumor when surgica1 re-expIoration was performed for an active anastomotic ulcer at site of the gastroduodenostomy, fourteen months foIIowing vagotomy and antra1 resection for chronic duodena1 uIcer. A high gastric reresection was done, with BilIroth II gastrojejunostomy. He has had a satisfactory course for four years foIIowing his operation. The seventh patient had clinical and roentgenoIogic evidence of a recurrent uIcer four months after vagotomy and antrectomy. This patient is in the process of being further evaIuated. The cause of recurrent uIceration is stiI1 unknown, and reoperation has not yet been performed.

he noted that ninety-one patients (9 per cent) have gained IO per cent or more than their idea1 weight. Neither macrocytic or microcytic types of anemia have been a prohIem in the postoperative course of any of the patients in this series. Postoperative diarrhea has been a minor problem in this group. After specific careful questioning of the patients, it has been determined that approximately IO per cent of the patients in this series have occasional miId diarrhea. In less than I per cent has diarrhea been judged as moderate or severe. RECURRENT

ULCERATION

In seven patients in the study recurrent uIceration has deveIoped, an incidence of 0.6 per cent. (Fig. 5.) Four of these seven patients have been reoperated upon and found to have had an incompIete vagotomy. Following transection of an intact vaga1 nerve trunk, three patients have been free of gastrointestinal symptoms from one to three years after reoperation. The fourth patient died of an esophagea1 pkrforation foIIowing his reoperation. The fifth patient had surgica1 re-exploration for sudden massive hemorrhage and a posterior waI1 duodena1 uIcer was discovered. She had previousIy had vagotomy and hemigastrectomy

358

Vagotomy

and

AntraI

Resection

reduce mortality rates, we have recentIy tended to use vagotomy and a drainage procedure, usuahy pyIoroplasty, in Iieu of antra1 resection in certain selected patients who inetude the geriatric patients and poorly nourished, underweight patients, especiahy women, and patients who present technica probIems too dangerous for resection. A review of our experience with vagotomy and a drainage procedure reveaI a 13 per cent incidence of recurrent uIcer; however, not a singIe recurrent uIcer was observed in a femaIe patient [6]. With any serious question concerning postoperative nutritiona status or operative risks, we are currentIy incIined to eIect vagotomy and a drainage procedure rather than resection in the femaIe patient. In those few patients in whom a Iarge inff ammatory mass about the duodenum precIudes resection or pyIoropIasty, we wouId elect vagotomy and gastroenterostomy. AIthough satisfactory results have been obtained with both the Billroth I and Billroth II types of anastomosis, the Billroth I type of reconstruction foIIowing vagotomy and antrectomy appears to have certain physioIogic advantages. Nutritiona studies would indicate diminished loss of fecal fat and nitrogen when duodenal continuity is maintained [ro]. The low incidence of excessive weight loss is attributable to conservation of an adequate gastric reservoir and may or may not be related to the type of gastrointestinal continuity. The incidence of dumping symptoms following vagotomy and antrectomy is similar to that folIowing any operative procedure for duodenal ulcer, in which the integrity of the pyIoric sphincter is lost. We believe that dumping can be minimized by instructing patients on a carefuhy pIanned postgastrectomy dietary regimen before discharge from the hospita1 [20]. High protein, high fat, and Iow carbohydrate foods are advised in the diet and the patients are aIso asked to abstain from liquids with their meals for an hour after eating. After an assessment of the patient’s toIerance to carbohydrates within the first few weeks following operation, the dietary regimen can be IiberaIized so that the majority of our patients are able to eat a normal diet without any restrictions. Our operation of choice in the surgica1 treatment of duodena1 uIcer in a patient who is a good risk is vagotomy combined with excision

COMMENTS

The aim of definitive surgica1 treatment for duodena1 ulcer is to ehminate the hypersecretion of acid, preserve an adequate gastric reservoir, be technically simpIe, have a low mortahty rate, provide for good postoperative nutrition, and take care of a11 the complications of duodenal ulcer. The clinical data presented in this report supports the conclusion that vagotomy combined with excision of the gastric antrum meets these aims. The operation of vagotomy and antrectomy approaches the probIem from the physiologic basis of eliminating both the cephahc and gastric sources of stimulus to the parietal ceII mass and Ieaves a Iarge gastric reservoir aImost achIorhydric. Ninety-three per cent of patients have obtained good to exceIIent results, and in onIy seven patients or 0.6 per cent has recurrent ulceration developed. SimiIar experiences with vagotomy and antrectomy in the surgical treatment of patients with duodenal ulcer have been observed by others [r6-181. The long-term resuIts have been associated with few undesirable sequelae. The probIems of nutritiona deficits, anemia and excessive weight Ioss that were common after an adequate subtotal gastrectomy procedure do not pose major problems foIlowing vagotomy and 40 per cent antraI resection. The remarkabIy low uIcer recurrence rate has been one of the outstanding benefits. Cohective data from other series comprising a group of over 3,500 patients show that the rate of ulcer recurrence is only 0.5 per cent. This figure is impressively Iower than the recurrence rate following either vagotomy and pyIoropIasty, vagotomy and gastrojejunostomy, or adequate subtota1 resection. Criticism has been directed at the operative mortality rate, especially by the proponents of vagotomy and a drainage procedure. The operative mortality rate of 2.7 per cent in this series compares favorabIy with the operative mortahty rate of subtotal gastrectomy in similar Iarge series of patients with complicated duodenal ulcer. In the early years of this series, vagotomy and antraI resection was used as a surgical procedure in every patient operated upon for duodena1 uIcer. This incIuded many elderIy patients who were poor surgica1 risks and many patients who were operated upon for massive hemorrhage. In an attempt to 359

Edwards,

Edwards,

Sawyers,

Gobbel,

of the gastric antrum. Vagotomy combined with a drainage procedure is a compromise operation, Iargely because of the higher rate of recurrent uIcer; but because of its generaIIy Iower mortaIity rate, it is an acceptabIe operation in the conditions previously mentioned. The operative procedure must be selected which best serves the individua1 patient. It is estimated at the present time that over 90 per cent of our patients with surgicaIIy significant duodena1 uIcers are currentIy undergoing vagotomy and antrectomy. In those few patients in whom uIcer recurrence has developed, it is beIieved that these recurrences are not faiIures of the pIan of operation, but failures in proper execution of operative procedure. Six of these patients probably had incompIete vagotomies and one had a ZoIIinger-EIIison pancreatic isIet ceI1 tumor which was not observed at the time of resection. Each of these recurrent uIcers has been observed within two years of the time of vagotomy and antrectomy, unlike recurrences foIIowing vagotomy and gastroenterostomy in which the incidence of uIcer recurrence has increased with the length of time of foIIow-up study.

Herrington

and

Scott

REFERENCES

rg6z. I. S~IITHWICK, R. H. Personal communication, 2. MARSHALL, S. F. Persona1 communication, rg6o. 3. WOODWARD, E. R. Persona1 communication, 1960. 4. DRAGSTEDT, L. R. Vagotomy for gastroduodenal u&r. Ann. Surg., 122: 973, 1945. 5. DKAGSTEDT, L. R. Cause of peptic ulcer. J. A. M. A., 169: 203, 1959. 6. EDWARDS, L. W., CLASSEN, K. L. and SAWYERS, J. L. Experiences and concepts regarding vagotomy and a drainage procedure for duodenal uIcer. Ann. Surg., 151: 827, 1960. 7. WALTERS, W. and MOBLEY, J. E. Five to ten year foIIow-up of 162 cases of duodena1 uIcer treated by vagotomy with and without associated gastric operation. Arch. Surg., 68: 163, 1956. 8. WEINBERG, J. A. Persona1 communication, 1962. g. FARRIS, J. M. Persona1 communication, 1960. 10. FARMER, D. A. and S~IITHWICK, R. H. Hemigastrectomy combined with resection of the vagus nerves. New England J. Med., 247: 1017, 1952. 11. EDWARDS, L. W. and HERRINGTON,J. L., JR. Efftcacy of 40 per cent gastrectomy combined with vagotomy for duodcna1 ulcer. Surgery, 41: 346, 1957. 12. EDWARDS, L. W. and HERRINGTON, J. L., JR. The technique of vagus nerve resection. Am. Surgeon, 20: 872, 1954. 13. LANDBOE-CHRISTENSEX, E. The extent of the pyIorus zone in the human stomach. Acta path. et Microbial. Scandinar., 54: 671, 1944, 14. HERRINGTON, J. L., JR. Editorial, the pyloric antrum, the reIative extent of dista1 gastrectomy necessary to insure its compIete extirpation. Surgery, 44: 775, 1958. 15. SCOTT, H. W., JR., HERRINGTOX, J. L., EDWARDS, W. H. and SHULL, H. J. The hazards of antral excIusion with vagotomy in the surgical trcatment of duodenal ulcer. Ann. Surg., 151: 181, 1960. 16. HARKINS, H. N., JESSEPH, J. E., STEVENSOX, J. K. and NYHUS, L. M. The “combined” operation for peptic ulcer. Arch. Surg., 80: 743, 1960. 17. COFFEY, R. J., NIEDFIELD, S. F., BYONE, W. D., BLUMBERG, J. J. and LAPADULA, M. F. Vagecand gastroduodenoshemigastrectomy, tomy, tomy in treatment of duodena1 uIcer. Am. J. Digest. Dis., 5: 324, 1960. 18. ZOLLINGER, R. M. and WILLIAMS, R. D. Considerations in surgica1 treatment for duodenal ulcer. J. A. M. A., 160: 367, 1956. 19. EVERSON, T. C. An experimenta comparison of protein and fat assimiIation after BiIIroth I and BiIIroth II reconstructions and segmental types of subtota1 gastrectomy. Surgery, 36: 525, 1954. 20. SCOTT, H. W., JR., WEIDNER, M. G., JR., SHULL, H. J. and BOND, A. G. The dumping syndrome. II. Further investigations of etiology in patients and experimenta animaIs. Gastroenterology, 37:

SUMMARY

A review has been made of our experience in 27 patients who have undergone vagotomy and antrectomy for the complications of duodena uIcer. The foIIow-up study has extended from Iess than one to more than fifteen years. The over-a11 results have been quite satisfactory with 93 per cent of the patients having had an exceIIent or good resuIt foIIowing operation. The incidence of recurrent ulcer remains very Iow, onIy 0.6 per cent. The operative mortality of 2.7 per cent in the series is in keeping with that of other resports. Nutritiona diffIcuIties, weight Ioss, diarrhea and anemia have not been major probIems. The operation of comptete abdominal vagotomy and excision of the gastric antrum successfuIIy controIs the uIcer diathesis; and in our opinion, is the most satisfactory surgica1 for the treatment of duodena1 procedure ulcer. I, I

194~ 1959.

360