TRANSTHORACIC VAGOTOMY FOR STOMAL ULCERATION

406 2. That the observed change was not solely due to large swings in intrathoracic pressure we confirmed by constricting the airway of the apparatus while the subject maintained a normal rate and depth of breathing. This procedure did not alter the value of DL, although respiratory pressure swings of 40-50 cm. of water were induced which are of the same order as those encountered during vigorous hyperventilation with a free airway. 3. We carried out the tests with the subjects breathing with their chests voluntarily held above the resting respiratory position so that the volume of gas contained by the lungs at the end of each breath was up to 21 above normal. This manoeuvre had no effect on the diffusing capacity, confirming Marshall’s previous findings (Marshall

1958). 4. Finally we arranged our apparatus so that the subjects hyperventilated against a constant positive pressure of about 15 cm. of water; the object of this manoeuvre was to drive blood out of the lungs and thus, on our hypothesis outlined above, to prevent or limit the expected increase in DL. This experiment failed to achieve its object, probably because the pressure used was too low; pressures higher than this could not be tolerated long enough for the tests.

Our thanks are due to Dr. J. G. Scadding and our laboratory staff who have helped us considerably in the production of this work. REFERENCES

Bates, D. V., Boucot, N. G., Dormer, A. E. (1955) J. Physiol. 129, 237. MacNamara, J., Prime, F. J., Sinclair, J. D. (1959) Thorax, 14, 166. McNeill, R. S., Rankin, J., Forster, R. E. (1958) Clin. Sci. 17, 465. Marshall, R. (1958) J. clin. Invest. 37, 394. Ross, J. C., Frayser, R., Hickam, J. B. (1958) ibid. p. 926. Turino, G. M., Brandfonbrener, M., Fishman, A. P. (1959) ibid. 38, 1186.

TRANSTHORACIC VAGOTOMY FOR STOMAL ULCERATION CHARLES WELLS

M.B. Lpool, PROFESSOR OF

M.B.

SURGERY,

F.R.C.S.

UNIVERSITY OF LIVERPOOL

REUBEN SILBERMAN W’srand, F.R.C.S., F.R.C.S.E.

LECTURER IN SURGERY IN THE UNIVERSITY

STOMAL ulceration following gastric resection is not while stomal ulceration following gastroenterostomy is seen only as an occasional legacy of the past. Both these groups of cases can be treated by gastric resection with excision of the ulcer, which may or may not include an abdominal vagotomy. Abdominal vagotomy common,

alone, as a planned procedure, may prove very difficult; and, whether it be difficult or easy, the surgeon may be tempted to change his plan and resect an ulcer mass that would be better left alone. Transthoracic vagotomy, as procedure, is an alternative which offers certain definite advantages such as technical ease, very low morbidity and mortality rates, and freedom from the sequelae of extensive excision of the stomach. We describe here our results with this procedure.

the sole

April we reviewed all the cases of stomal ulceration the professorial unit at the Liverpool Royal Infirmary between December, 1952, and mid-1957 and treated solely by transthoracic vagotomy. All but a few 2 remain were personally questioned and examined. untraced (a common experience in a seaport town), leaving for assessment 23 (17 males, 6 females), the youngest of whom was 28 and the oldest 73 at the time of operation. Last

seen

on

Barium-meal examination had provided definite evidence of ulceration in 12 cases and suggestive evidence in 4. In the remaining 7 there were strong clinical grounds (severe epigastric pain, vomiting and/or bleeding) for the diagnosis of stomal ulceration. Gastroscopy was carried out in some cases, but gave little help. Fractional test-meal was performed in most cases, provided supportive evidence in 11 where high or

TABLE I-RESULTS OF TRANSTHORACIC VAGOTOMY FOR STOMAL ULCERATION

" 1. Double-lumen gastrojejunal anastomosis of the pantaloon " type. 2. End-to-side gastroduodenal anastomosis with wide stoma. 3. Colonic implant between stomach and duodenum with reversed stalsis.

peri-

average acid levels

were found. Negative findings in test meals after gastric operations are notoriously unhelpful. We have not used the insulin-provoked test meal’for gastric acidity after vagotomy. Today the twelve-hour overnight secretion would ordinarily be estimated, but this was not done routinely in our series.

No deaths had resulted from the operation nor any major complications. While in hospital some patients had had segmental left-lower-lobe collapse with a small effusion, and for a few months after operation a minority complained of wound pain. Results

The results

are

summarised in table

i.

Gastroenterostomy group (4 patients).- The stomal ulceration had developed fourteen to twenty-five years after gastroenterostomy. Vagotomy relieved all four patients of their ulcer symptoms and they were well at the time of follow-up. Gastric-resection group (19 patients).-The majority had previously had more than one operation. In 13 all symptoms were removed by thoracic vagotomy and 11 of these were well at the time of follow-up. The other 2 had died from unrelated causes. The first had developed stomal ulceration after a Steinberg gastrectomy and was relieved by vagotomy; but he died six years later from carcinoma of the bladder. The second, whose stomal ulcer followed a Billroth I gastrectomy for gastric ulcer, was also relieved by vagotomy but died of cirrhosis of the liver nine months after the operation. Of the remaining 6 (unrelieved) cases, no fewer than 4 proved to have been badly selected. 1 patient, who had had a Roux-Y gastrectomy, was a chronic alcoholic and was afterwards admitted to a mental home. The other 3, who had complained of epigastric pain and vomiting, were found at subsequent laparotomy to have no evidence of stomal ulcer, active or healed. Their histories are: CASE A (Steinberg gastrectomy).-1951: gastropexy elsewhere for partial gastric volvulus. 1952: Steinberg gastrectomy for duodenal ulcer and hiatus hernia. 1953: transthoracic vagotomy (confirmed histologically) failed to relieve persistent epigastric 1958: no ulcer found at laparotomy. Converted to pain. " Moroney ". Since then the attacks of epigastric pain have been less frequent; they seem to have been due to intestinal

hurry. CASE B (modified Billroth 1).-1952 : pylorectomy and vagotomy for duodenal ulcer, performed elsewhere. 1953: modified Billroth i for persistent duodenal ulcer. 1957: transthoracic vagotomy. On histological examination, amputation neuromata found. Symptoms unrelieved. Roux-Y conversion carried out as a last resort but without improvement. CASE C (Moroney).-1926: gastroenterostomy. 1946-47: Polya gastrectomy for recurrent ulceration. Severe nutritional deficiencies followed (anaemia, pellagra, riboflavin deficiency) probably as a result of extreme intestinal hurry (barium was

407

demonstrated in the caecum an hour after ingestion). 1952: Moroney conversion for intestinal hurry. 1953: transthoracic vagotomy for suspected stomal ulcer. 1956: Roux-Y conversion after excision of colonic implant (no ulcer found). Pain, vomiting, and nutritional deficiencies persist, albeit to a lesser extent. A recent barium meal was negative. Fasting test-meal showed achlorhydria.

In the 2 other patients stomal despite transthoracic vagotomy.

ulceration continued

CASE D (modified Billroth 1).-1953: Modified Billroth I, with abdominal vagotomy for duodenal ulcer. 1955: transthoracic vagotomy for a stomal ulcer (bilateral vagal-nerve section was confirmed on histological examination). 1957: insulin test-meal at blood-sugar 35 mg. per 100 ml. produced 100 clinical units of total acid. Further one-third gastric resection with Polya anastomosis for posterior stomal ulcer. Has since remained very well. CASE E (Moroney).-1949: Polya gastrectomy elsewhere (apparently no ulcer was found). 1952: converted to Moroney for intractable dumping. Abdominal vagotomy. 1952 : 6th-9th left intercostal nerves crushed for severe epigastric pain, without relief. 1953: transthoracic vagotomy (fractional test-meal showed hyperchlorhydria). Histological proof of bilateral One week after operation, test-meal vagotomy obtained. showed achlorhydria. 1957: radiography revealed stomal ulcer. Gastric acidity high. A large stomal ulcer was resected and the anastomosis converted to a Roux-Y type; an abdominal vagotomy was also done. The patient has since remained well. Discussion

The numbers in this series are small, and in the discases there was an almost bewildering variety of antecedent procedures. Perhaps the most striking fact is that stomal ulceration following uncomplicated Polya gastrectomies (5 cases) or gastroenterostomy (4) was always completely relieved by transthoracic vagotomy. Study of the literature suggests that, after gastrectomy, the operation of choice is vagotomy alone, which may be

appointing

TABLE

II-PREVIOUSLY REPORTED RESULTS OF VAGOTOMY FOR STOMAL ULCER

vagotomy for duodenal ulcer, and a proportion of recursurely be expected. A priori thoracic vagorelieve such ulceration. Our own practice should tomy has been to employ vagotomy as a routine at the time of the gastrectomy or deliberately across the chest at the same or a second operation in cases of difficulty. Of a series of such operations (Wells and Johnston 1955) stomal ulceration has been suspected in only one. In that one case (which we have mentioned above) the diagnosis was neither confirmed nor disproved: the symptoms were not relieved, but the patient, a chronic alcoholic, has been admitted to a mental institution. Nothing can be deduced except that he was a bad subject for any operation. Our two cases in which stomal ulceration persisted after thoracic vagotomy are of special interest. It is disturbing that, despite removal of the pyloric antrum and resection of the vagus nerves-attempted and apparently achieved from both below and above the diaphragm, and confirmed histologically-enough acid remained or recurred to provoke further ulceration. How this residual acid was produced remains in some doubt: we do not know whether resection of the nerves was incomplete, whether regeneration took place, or whether a hormonal factor was responsible. But the relapses did in fact occur, and in both cases the ulceration was then apparently relieved by a high gastric resection. This satisfactory endresult presumably excludes the possibility of their being examples of the Zollinger-Ellison syndrome. Possibly the initial antral resections went insufficiently high on the lesser curvature. rences must

Conclusions

1. Transthoracic vagotomy is simple and safe. 2. It is probably the best means of treating stomal ulceration following otherwise uncomplicated gastrectomy, or following gastroenterostomy provided the stoma is well placed and functioning satisfactorily. 3. The diagnostic proof of stomal ulceration is not easy. Estimation of night secretion, not routinely available at the time of this study, may prove invaluable. Persisting acid is a reasonable indication for vagotomy.

always

4. On a-priori grounds, vagotomy is necessary in operations of the Billroth i type for duodenal ulcer. If acidity persists after abdominal vagotomy, thoracic vagotomy should be undertaken as an adjuvant. 5. In patients who have undergone bizarre or multiple operations on the stomach and duodenum, accurate

expected

to

relieve stomal ulceration in three

cases out

of

every four

(table 11). Our figures support this view with 13 successes in 19 cases. Walters (1959) has suggested that stomal ulceration following gastroenterostomy is somewhat less favourably affected by vagotomy alone (table 11) and that in these cases gastric resection is to be preferred. Gastric resection, however, is an operation with its own mortality and morbidity, and we have chosen to try the lesser procedure first. The fact that this succeeded in all 4 indicates that, if the gastroenterostomy is well placed and functioning satisfactorily, transthoracic vagotomy is a sound procedure. On stomal ulcer after Roux-Y gastrectomy the literature is not informative. Some surgeons are at present performing an elective Roux-Y gastrectomy subtotally without

diagnosis may be difficult. The surgeon must weigh the dangers and complications of a further abdominal operation against the advantages of actually seeing the lesion. In the presence of pain suggestive of ulcer, and of continued night secretion of acid, thoracic vagotomy is safe and worth while. 6. In some late and complicated cases, disappointments inevitable whatever is done. It is sententious and not really helpful to suggest that the solution lies in more careful selection in the first place. are

REFERENCES

Crile, G. J., Jr., Brown, G. M. (1951) Gastroenterology, 17, 14. Davey, W. W. (1959) Ann. R. Coll. Surg. 24, 277. Hand, B. H., Patey, D. H. (1953) Brit. J. Surg. 41, 161. Knox, G. W., West, J. P. (1959) Ann. Surg. 149, 481. Osnes, Sv. (1955-56) Acta chir. scand. 110, 373. Walters, W. (1959) Arch. Surg. 78, 516. Chance, D. P., Berkson, J. (1955) Surg. Gynec. Obstet. 100, 1. Wells, B. W. (1954) Lancet, i, 598. Wells, C. A., Johnston, J. H. (1955) ibid. i, 937. —