Transpleural bilateral vagotomy with vagus resection for peptic ulcer

TheAmerican Journalof

krgery

Copylght,

A

PRACTICAL

1949 by The ‘Yorkc Publishing Co., Inc.

JOURNAL Fiftydghth

VOL.

JUNE,

LXXVII

BUILT

Te~ear of

ON

MERIT

Publication NUMBER

1949

SIX

Editorials TRANSPLEURAL BILATERAL VAGOTOMY WITH VAGUS RESECTION FOR PEPTIC ULCER*

T

HE ultimate

goal of internists and surgeons aIike seems to have been by the sectioning of both reached tenth cranial nerves either above or below the diaphragm, particularly for intractabIe, non-obstructing duodena1 ulcers. The ideal candidate for this operation is the chronic dyspeptic who has suffered for many years with a non-obstructing duodenal ulcer without responding favorably to adequate medical treatment, such :ts mental and physical rest, diet and medication. This type of patient has the we11 known history of persistent ulcer pain and gastric distress with vomiting and resultant loss of weight, sIeep, appetite and strength. The individua1 often paces the Boor during the night because of recurrent pain and discomfort; he or she cannot earn a living or enjoy life. In fact, many such patients contemplate suicide. ApproximateI> seventy patients with acute, perforated peptic ulcers are admitted to our wards yearIy. These ulcers should be closed promptIy by the surgeon. One of my patients, who had a nonobstructing duodenal ulcer, had :I perforated duodenal ulcer some J-ears earlier. He \vas a candidate for vagotomy. While he was being worked up for a tenth nerve * Presented

at the

Boston

City

Hospital

Alumni

section in this hospital, his ulcer perforated a second time before I was ready The Ma>.o Clinic has to do a vagotomy. reported perforations just after vagotomy. I have had many duodenal uIcers perforate a second year in succession; several had perforated three years in succession and one individual had a perforated duodena1 ulcer once a year for four years in succession. It is probable that if duodenal ulcer is about to perforate in a patient a second time or more, vagotom! wiI1 not prevent this occurrence if tenth nerve section is performed about the time the perforation is readv to occur. It is possibIe that after a patient has recovered from a perforated peptic uIcer operation, vagotomy, some time subsequently, might we11 pre\,ent repeated perforations provided no obstruction is present at the I>>-lorus. Obstructing ulcers at or near the pylorus do not Iend themsel\.es to \xgotomy alone since the resultant atony, lessened peristaIsis and delayed emptying of the stomach folIowing vagotomy wouId ng:grn\-ate the obstruction. Standard gastric surgical operations, such as resection of the stomach or gastro-enterotomy, may be done successfuIIy, with or without vagotomy, through the abdomen.

Association Amphitheatrr.

679

Clinical

VIeeting,

hlay

3, rc)l:,

:It the. Cherkcr

680

EditoriaIs

Patients with recurrent bIeeding peptic or jejunaI uIcers in the interva1 between hemorrhages have been operated upon by me. A biIatera1 vagotomy through the chest is done; the nerves are resected at the same time. It is not particuIarIy desirabIe to perform a vagotomy operation aIone on gastric uIcers because of the danger of malignancy. Many years ago Berg of New York resected the left vagus nerve subdiaphragmaticaIIy whiIe at the same time performing a subtota1 gastrectomy for duodena1 uIcer in young peopIe with a high acidity. It has been proved that section of one vagus nerve is of IittIe or no vaIue. Both nerves and any communicating branches shouId be severed and excised to obtain satisfactory resuIts. The Iate distinguished surgeon, Dr. Harvey Cushing, maintained that nerve impuIses from the brain were the important factors in the cause of peptic uIcers. The recent fine work of Dragstedt in Chicago, Moore in Boston and others has Ient confirmation to this beIief. Some fifteen years ago I -was the first surgeon at the Boston City HospitaI to remove the whoIe stomach successfuIIy for carcinoma invoIving both cardiac and pyIoric regions of the stomach. An endto-side anastomosis was performed between the esophagus and jejunum through the abdomina1 approach. SecondariIy, both tenth nerves were sectioned in doing this compIete gastrectomy. Dragstedt has approached this probIem by sectioning the tenth nerves above or beIow the diaphragm, in the Iatter case often combining vagotomy with standard operative procedures on the stomach and duodenum. Moore has confined his efforts to sectioning and resecting the nerves above and through the diaphragm by means of a transpIeura1 approach aIone. I have operated upon a series of patients, doing a biIatera1 vagotomy with vagus resection at the Boston City HospitaI and eIsewhere, with no operative mortaIity.

A transpIeura1 approach has been made use of in a11 of my cases since in my hands this method affords the operator a better opportunity of sectioning both crania1 nerves and connecting pIexuses intact. I have noted considerabIe differences in the size, shape and position of these tenth nerves as we11 as the connecting nerve fibers on the esophagus. If by some adhesions the Iung is adherent to the diaphragm or parieta1 pIeura as a resuIt of prior pIeurisy, these adhesions must be severed in order to retract the Iung properIy and approach the esophagus through the posterior mediastinum. Very dense and extensive adhesions of the Iung to the diaphragm, which I have encountered, require approach to both tenth nerves through an incision in the into the abdomina1 cavity, diaphragm, through the transpIeura1 approach. Both tenth nerves beIow the diaphragm break up in a pIexus of nerve fibers making their more diffIcuIt than compIete severance above the diaphragm. The Ieft anterior vagus nerve is more readiIy accessibIe than the right posterior tenth nerve, which may be found posteriorIy and further away from the stomach than the anterior vagus branches. At operation the patient is pIaced on the right side, and under intratrachea1, positive pressure anesthesia the Ieft chest is opened by subperiosteaIIy removing the seventh or eighth rib from the Costa1 cartiIage anteriorIy to its transverse process attachment posteriorIy. A rib spreader is inserted and any adhesions of the Iung to the diaphragm or chest waI1 are separated if possibIe. If dextrocardia is present, the right chest wouId be opened. The Iigament of the Iung is then doubly cIamped and tied off, retracting the Iung upward and protecting it with moist pads. The posterior mediastinum is opened between the heart and aorta, and by bIunt dissection the esophagus with the right and Ieft tenth crania1 nerves are puIIed into the Ieft chest. The Ieft anterior vagus nerve is identified American

Journal

of Surgery

Editorials and lifted up on a blunt hook, freeing it from its bed upward toward the hilum of the Iung and downward to the diaphragm. The proxima1 part of the tenth nerve is then injected with I per cent novocain solution before it is tied with a gastrointestinal silk suture distal to the injected area in order to avoid shock. A surgeon’s knot is used to prevent the tie coming off the nerve. l’he distal tenth nervFe is then tied OR‘ at the diaphragm lvith catgut, otherwise a small blood vessel accompanving the nerve may bleed. SeveraI centimeters of the vagus nerve are excised and placed by Zenker’s soIution for examination by the Pathological Department. The right posterior tenth nerve is treated simiIarIy; then both proximal ends of the nerves are pulled up into the Ieft pIeura1 cavity and sutured to the suture line of the parietai pleura in closing the posterior mediastinum. This procedure prevents nerve regeneration between the proximal and distal ends of the tenth nerves. About ten minutes are ahowed the expert anesthetist to expand the Ieft lung fuliy. During the operation it is we11 to expand the left lung partiaIIy by positive pressure once or twice. A small catheter is left in the posterior end of the incision in the most dependent part of the pleural cavity during the chest cIosure, then the catheter is removed on final cIosure. A heavy mattress suture, placed temporarily about the adjacent ribs, aids in closure of the chest. The patient is watched closely for evidence of pneumothorax, fluid in the chest, atalectasis or other respiratory compIications. The individua1 is aIIowed to be up and about the day after operation. Some patients develop a certain amount of fluid or air in the pIeura1 cavity, despite full expansion of the lung at cIosure of the chest wall. Others complain of pain in the region of the intercosta1 nerve which may be anticipated by the injection of nupercain in oil in the proxima1 region of the intercosta1 nerve before cIosing the chest. .June,

I 949

681

Some anesthesia in the epigastrium has been noted during convalescence. Atony of the stomach may necessitate the use of a duodena1 tube to reIieve a sense of fuIIness in the stomach and to prevent vomiting. Nature eventuahy accommodates itself to the lessened peristalsis; and there is no need for a gastro-enterostomy as the pyIorus will be found to be patent, if this unnecessary operation is subsequentIy performed for stomach atony. Before operation these patients are gastroscoped and the gastric acidity is aIso noted before and after operation with insuIin and histamine tests. The resuIts of the operation are lessened gastric peristaIsis, marked decrease in gastric acidity and a slowing down of the emptying of the stomach due to a certain amount of atony. The patient has a sense of we11 being; his pain has disappeared. A better than norma appetite dev.elops and the patient gains weight, sleeps we11 and is surprised that he can eat formerly forbidden fruits, tomatoes, etc. He can now enjoy Iife and return to work to support the family. Since the liver, pancreas and intestines as we11 as the stomach are suppIied by the tenth nerves, one would expect that the function of these organs wouId be affected by this operation. Many of these patients have normal motiIity and no symptoms a year after operation. CIinicaIIy, the patient often gains 20 to 30 pounds after operation and many deveIop a ravenous appetite, for instance, eating severa orders of ham and eggs or other articIes of food at a mea1. These patients are x-rayed before and after operation. Clinically and from an x-ray point of view, the active ulcer disappears in a matter of weeks after operation. Stomach motiIity returns to normal in many cases. Others, with atony of the stomach and sluggish peristalsis, are clinicaIIy weIl. Penicihin has been given as a routine, 30,000 units every three hours for twenty-

682

EditoriaIs

four hours then IOO,OOOunits every eight hours for three days. EIsewhere some patients have been operated upon for non-obstructing duodena uIcer as shown by repeated x-rays, and a transpIeura1 biIatera1 vagotomy has been performed without relief of symptoms. At subsequent abdomina1 operation a pathoIogic condition has been found in the head of the pancreas or eIsewhere. At some future date it may be advisabIe during transpIeura1 vagotomy to open the diaphragm and inspect and paIpate the

stomach, duodenum, or other abdomina1 disorders. In

my

vagotomy nerves taIity

opinion, with

is much and

transpIeura1

resection simpIer,

is preferabIe

trectomy

for

duodenal

margina

recurrent

gaIIbIadder, pancreas organs for unknown

intractabIe

bleeding

of

biIatera1 both

tenth

has a Iower morto a partiaI

gas-

non-obstructing

or jejunaI

uIcers

duodena1

uIcers in the period between

or

and

jejunaI

hemorrhages.

WILLIAM REID MORRISON, M.D.

American

Journal

of Surgery