Vagotomy and pyloroplasty for bleeding duodenal ulcer

Vagotomy

and Pyloroplasty for Bleeding Duodenal Ulcer A NOTE

JACK

MATTHEWS

FARRIS,

ON SELECTIVE

M.D. AND

GORDOK

KNIGHT

From the Department oJ Surgery, University cd CuliJwnia at Los Angeles and from tbe Department of Surgery, Uni versity of Soufbern Calijornia, Los Angeles, Calijornia. 2.5 million persons in the United States suffer from peptic ulcer, fifteen persons per one thousand of popuIation. A significant number of these patients will ultimateIy require surgicai treatment because of complications. Of these complications, bteeding is the most frequent. For exampIe, in our series of z I: patients who have been treated by vagotomy and pyloropIasty for duodenal uIcer, seventy-six were operated upon because of hemorrhage, about one of three. In fifty of these patients, the extent of the bleeding qualified as “massive” with hemogIobin levels of 8 gm. per cent or less and/or required at Ieast 2,000 mI. of blood to restore circulation to normotensive IeveIs. ApproximateIy half of the patients in the group were between the ages of “massive” fifty and sixty; five were between the ages of sixty-five and seventy; seven between the ages of seventy and seventy-five; one between seventy-five and eighty; and tMo between eighty-five and eighty-nine years, None of these patients has been lost to follow-up study, and the average time since operation is 54.5 months. PPROXIMATELY

A

GENERAL

CONSIDERATIONS

It is unfortunately true that during the past decade the mortality rate from duodena1 ufcer has increased sIightIy despite increased utiIization of surgical treatment. A possible expIanation for the Iatter, particuIarIy in bIeeding ulcer, is that operation has frequentiy been postponed too Iong and “failure” of conservative treatment resuIts in deterioration of the AmericanJournal

oj Surgery,

Volume

107, March

1963

388

VAGOTOMY SMITH,

M.D., Los Angeles,

Calijornia

patient and, in retrospect, operation should have been done at the time of, or shortIy after, admission to the hospita1. \Vith these considerations in mind and stimulated by Weinberg and associates [I] at Long Beach Veterans HospitaI, in December of 1952 a sixty-three year old patient with severe Parkinson’s disease and a seven year history of an uIcer was operated upon follolving a recent episode of meIena and shock. Twenty-five hundred mI. of Mood were required to maintain circuIation, aIthough lowest hemogIobin levels were 9.9 gm. per cent. At operation, an uIcer crater with a spurting bIood vesse1 was treated by suture ligature, pyloropIasty and vagotomy. This patient made a prompt recovery and has now been followed-up for nearIy ten years and is weI1. Following this experience, severa other patients who were poor risks were operated upon by this relatively new and simple operation. In one or two instances, patients in critical conclition with spurting vesseIs in the base of the uIcer survived. There was reason to beIieve that they might not have survived if a more formidabIe operation had been done. This preliminary experience was reported in 1958 [2] upon a total of twenty-one patients and again in 1960 [J], at which time the total had increased to forty-eight patients (thirty of them “massive”). At this particuIar time, there were two deaths, one caused by cerebral vascuIar accident and one caused by cardiac arrest. In both, the immediate bleeding problem was soIved. One of these patients was eighty-eight years oId and would not have been operated upon except for the confidence in this new impIement at hand : namely, vagotomy and pyIoroplasty.

Vagotomy MANAGEMENT

and

Pyloroplasty

for Bleeding

DuodenaI

Ulcer

POLICY

This communication

a cona total

a trial

a bIeeding a third a quaIifying OPERATIVE FROM

MANAGEMENT THE

UPPER

GASTROINTESTINAL

a we11

PART

OF BLEEDING OF

THE

TRACT

When it is evident that the patient is bleeding, and the diagnosis of peptic ulcer is fairIy clear, as mentioned previously, the patient is taken to the operating room and as soon as a satisfactory circuIatory status has been achieved. Upon entering the abdomen, and when it is reasonably clear that the blood is coming from the stomach or duodenum, a gastroduodenotomy incision, approximately IO cm. in length and equally divided between the stomach and duodenum, is made. (Fig. I.) In those instances in which a bIeeding vessel can be visualized in the uIcer bed, it is firmly secured with deeply pIaced, stout, nonabsorbable sutures introduced in a direction roughly paraIIe1 to the long axis of the pancreatic duct. A muscIe graft is occasionaI1y used as a tamponade. If the bleeding has ceased and a thrombus is present, it is usually wiped away, producing renewed bleeding which is accurateIy controIled by ligature as described above. It is sometimes necessary to introduce a needle into the calloused base of the uIcer well into the substance of the pancreas where the posterior wa11 of the duodenum has been completely destroyed. This is particularly true in the socaIIed giant ulcers. We have had no difficulties, however, as far as injury to the pancreas is concerned. The pyloric canal is reconstructed with a singIe row of seromuscular sutures appIying the Heineke-Mikulicz principle. This technic avoids the mucous membrane and provides a maximum diameter for the duodenum. The Finney method (Fig. 2A, B, and. C) appears to be

a patient

In this connection, we beIieve that the initial hemorrhage from a duodena1 uIcer, regardless of the age of the patient, is more dangerous than is generally appreciated. Furthermore, the adage “operate over fifty” in our opinion is not tenabIe. The risk of second hemorrhage we believe to be about the same at a11 ages and approximately haIf of those who survive without operative treatment wil1 die, have other hemorrhages or submit to operation within five years [2]. Because of the confidence in the safety with which vagotomy and pyloroplasty may be done, the time interval between admission and surgical treatment has significantIy decreased; and patients are now operated upon earIier and in better condition than before. In this connection, some of these patients do not exhibit the criteria generally accepted in the past to qualify for the “massive” group, that is, they do not exhibit hemoglobin levels of 8 gm. per cent or Iess or require 2,000 m1. 389

Farris and Smith

FIG. I. A, IO cm. gastroduodenotomy exposing ulcer crater and eroded vessel. B, transfixion sutures through base of ulcer and at right angles to approximate course of gastroduodenal artery. C, seromuscuIar sutures with Heineke-MikuIicz reconstruction.

390

Vagotomy

and PyIoropIasty

for BIeeding

DuodenaI

UIcer

FIG. Iimbs of stomach and duodenum. B, posterior mucosai suture. C, continuous suture of inner anterior row. D, outer interrupted scromuscutar suture.

equally satisfactory and may be superior in those patients in whom the duodenum is exceedingly narrow. AImost without exception, al1 duodenums can be reconstructed suitabIy by one maneuver or the other, even in the presence of edema, induration or obstruction. The acuteIy perforated uIcer is easiIy handled by gastroduodenotomy and reconstruction by the HeinekeMikulicz principle. The success of pyIoropIasty depends upon its

ability to nullify the antral phase of hypersecreCon. When properiy constructed, in other words, it is a physiologic antrectomy. A pyloroplasty which empties poorIy, in our experience, is a more common cause of recurrence than incomplete vagotomy. Indeed, an obstructed pyIoric cana in the presence of vagotomy may result in a paradoxic increase in gastric acidity above preoperative IeveIs; however, a patuIous pyloric cana folIowing pyIoropIasty, will nuIIify antra1 hypersecretion and prevents the “jet egress” of 391

FIG. 3. “Blind” vagotomy and pyloroplasty. A, new incision for inspection of stomach is prcfernble to estensron of gastroduodenotomy incwon. B, inspection of esophngogastric juncture for (Mallory-W’eiss) mucosal lacerations. C, p,yloroplasty facilitated by separate gastrotomy incision.

392

Vagotomy

and

PyIoropIasty

for BIeeding

In either after

VAGOTOMY

PYLOROPLASTY

patients in duodena1 gastric,

a bleeding is demonstrabIe it is policy to a new in the portion of stomach (Fig. 3), and to carry out a meticulous inspection of the gastric fundus with particular attention to the esophagogastric junction. The hiallory-Weiss lesion, when present, can be visuahzed and dealt with by appropriate suture. Reconstruction of the pvIoric canal is facihtated when a separate incision has been used for the upper gastrotomy rather than extending the gastroduodenotomy incision itself. When no lesion is found or when the bleeding appears to be from a diffuse gastritis, vagotomy and pgIoroplasty have been a satisfactory soIution to the problem and are preferred to the so-called bIind gastrectomy. In our experience, if the source of the bleeding is unidentified by the usua1 measures before operation, it remains unidentified at operation in about a third of the patients. We particuIarIy eschew bhnd gastrectomy, inasmuch as it only succeeds if the unidentified lesion is in the lower third or haIf of the stomach or by reducing acidity with a beneficia1 effect upon some obscure duodenal Iesion. SELECTIVE

UIcer

Iiminary observation a possibihty appears that seIective vagotomy may preserve certain aspects of biliary and pancreatic function, which when destroyed by tota vagotomy may be responsible for diarrhea. We have studied a series of IOO patients with total vagotomy with particular emphasis upon this sy-mptom. Twenty-eight patients have definite changes in their bowel habits, consisting of diarrhea and/or In only one is the symptom even urgency. remotely disabling. Most are able to control these symptoms by dietary measures with avoidance of hyperosmotic stimuli (heat and cold, concentrated sweets, easily hydrolyzed starches and proteins). About half of these patients aIso have intermittent and mild symptoms of dumping (14 per cent). In forty patients who have undergone some type of serective vagotomy (both preserved, nineteen; anterior nerve only preserved, seventeen; and posterior nerve onIy preserved, four); the incidence of altered bowel function as determined by a recent study has been decreased by about half. There is no correlation with the type of selective vagotomy done. Obviously, at the present time experience is too Iimited for definitive evaIuation. Continuation of this study is pIanned. Gastric secretory studies, as in those of Griffith [5], indicate that this operation has achieved total vagotomy effect. The operation is infinitely more difhcuIt and, at the present time, we believe that the theoretic benefits, which might accrue from seIective vagotomy, are as yet not we11 documented and the innot creased effort invoIved is, therefore, justifiabIe except in ideal subjects. During a visit to the United States, Mr. Burge kindIy Ieft the Burge-Vane vagotomy test set [6]. After using it in approximately twenty-five patients, we have ultimateIy discontinued its use. Its accuracy (in our hands), which may be well altered by drugs, anesthesia, diaphragm motion and nerve trauma, is open to question. Furthermore, we believe that it is unnecessarily traumatic and adds considerable time to the operation. The esophagea1 tamponade is the most objectionable feature, and it is hoped that more refined methods may uItimateIy be developed.

gastric juice, which is undoubtedIy responsible for the fact that most duodenal ulcers are solitary and usually in the same Iocation, namely, the posterior and superior w-all of the first portion of the duodenum. Experience with this operation has shown that if the ulcer diathesis is properly solved regeneration of mucous membrane in the ulcer bed occurs rapidly; even giant ulcers of the duodenum disappear rapidly as observed by roentgenoIogic technics. These experiences also emphasize that the success of surgical treatment of duodena1 ulcer in no way is dependent upon excision of the ulcer itseIf. “BLIKD”

DuodenaI

VAGOTOMY

Continued efforts have been directed toward increasing the scope and accuracy of vagotomy. AIthough most of the patients herein reported have had a total vagotomy, during the past two years we have been interested in the seIective vagotomy, as popularized by Mr. HaroId Burge of London, and at the present time have carried out forty such operations. From a pre-

RESULTS

Three deaths have occurred in these seventysix patients. None is lost to fohow-up study. 393

Farris and Smith Two of the patients died from other causes (after the bIeeding had been successfuIIy controlled). One died from the late effects of cerebra1 vascuIar hemorrhage. The third patient, age seventy-seven years, succumbed from postoperative hemorrhage associated with a new, large, superficial, stress type of gastric ulcer after the origina bIeeding from the duodenal ulcer had been controlled. None of the patients

quentIy be ignored after ascertaining its benign nature. Evidence exists which suggests that pyIoropIasty alone may nuIIify the role of the antrum in the genesis of gastric uIcer just as effectiveIy as the Madlener operation (with the uIcer in situ) or actua1 resection. COMMENTS

Peptic uIcer was ranked as sixteenth in the cause of death in the United States in the year 1959. More people died in 1955 of duodenat and

in the entire group has been reoperated upon for bleeding during the immediate postoperative period, although, in retrospect, the Iatter patient may n-e11 have been saved by a secondary operation. Two other patients have been reoperated upon at intervaIs from three months to three years after the origina operation. One of these had a bonafide recurrent ulcer associated with a poorly emptying pyIoropIasty, and the other one showed simpIe gastritis. Three other patients have shown evidence of bIeeding episodes without uIcer symptoms. CarefuI roentgenologic and gastric secretory studies have faiIed to show evidence of recurrent uIceration. These three patients are now weI1. In a tota of 2 I 7 patients with duodena1 ulcer. who have been subjected to vagotomy and pyIoropIasty, since 1930 for a11 indications, onIy in three patients have bonafide recurrent duo-

gastric uIcers than of syphiIis, cancer of the esophagus, cancer or cancer of the uterus [2]. It is somewhat paradoxic that foration is generaIIy an absoIute immediate operation, the patient from 1,300 to 2,000 m1. of blood

poIiomyeIitis, of the Iarynx whereas perindication for who has Iost

is frequentIy treated for several days with the expective hope that the bIeeding may stop. The patient who has lost the same amount of bIood from other causes is operated upon at once or as soon as blood is available in sufficient amounts to support circulation. AIthough certain uIcers may stop bIeeding, it is important that many wiI1 not; it is dangerous to specuIate if a safe procedure is avaiIabIe. A realization and appraisa1 of the ease with which vagotomy and pyIoropIasty may be done wiI1 aIIow justifiabIe increase in utiIization of surgica1 treatment, so that these patients will arrive in the operating room in inliniteIy better condition than those patients who have been subjected to proIonged conservative or medical treatment, which uItimateIy faiIs.

dena ulcers deveIoped. AI1 three of these have achieved an exceIIent resuIt by the addition of antrectomy. Two more have been reoperated upon for what proved to be gastritis. The oldest patient has now been foIIowed for twelve years. It appears from these observations that antrectomy is necessary in Iess than 2.5 per

SUMMARY

cent of a11 patients with duodenal uIcers and, therefore, is reserved for those in whom the primary operation of vagotomy and pyIoroplasty shouId fai1. The secondary operation, when indicated, wiI1 insure a good resuIt. This aIIows a philosophy of surgica1 treatment which emphasizes that the success of operation is not dependent upon remova of the uIcer and/or the antrum, thereby avoiding the occasiona hazards of duodena1 cIosure and/or an attempt at gastroduodenostomy under adverse conditions, two of the important considerations in mortaIity and morbidity [7].

Seventy-six patients with bleeding duodena1 uIcer and treated by vagotomy and pyIoropIasty are reported. I.

2. Fifty of these patients quaIify as massive bteeders with hemogIobin IeveIs of 8 gm. per cent or less and/or required at Ieast 2,000 ml. of blood. A third criterion for definition of massive bIeeding: nameIy, shock is proposed. 3. The success of this operation depends upon an accurate vagotomy, a firm Iigature of the bIeeding vesse1 and a good functioning pyIoropIasty. 4. Preliminary experiences with forty seIective vagotomy operations over a two year period are reported. 5. Three deaths have occurred in the entire group. One of these couId have been prevented

In addition, certain cases of gastric prepyIoric uIcer have been successfuIIy managed by suture Iigature, vagotomy and pyIoropIasty with the uIcer Ieft in situ. When gastric uIcer and duodena1 uIcer coexist the former may fre-

394

Vagotomy

and

PyIoropIasty

for BIeeding

by reoperation. In two other patients death occurred from causes other than continued hemorrhage. 6. Of the remaining seventy-three patients, two others have required reoperation for bIeeding (late), one for recurrent duodena1 ulcer and the other for diffuse gastritis. 7. AccumuIative data from these experiences indicate over a tweIve year period that correction of the abnormal cephaIic and humoral phases of gastric hypersecretion associated in man with chronic duodena1 ulcer may be effectiveIy corrected by vagotomy and pyIoropIasty. Cognizance of this experience is important to those who are deaIing with a patient who is a poor risk and who is suffering from hemorrhage and in whom more formidabIe operations might be poorIy toIerated.

DuodenaI

UIcer

REFERENCES

I. WESTLAND, J. C., MOVIUS, II. J. and WEINBERG, J. A. Emergency surgical treatment of the severely bIeeding duodena1 uker. Surgery, 43: 897, 1958. 2. SMITH, G. I(. and FARRIS, J. M. RationaIe of vagotomy and pyloroplasty in management of bleeding duodena1 ulcer. J. A. M. A., 166: 878, 1958. 3. FARRIS, J. M. and SMITH, G. K. Vagotomy and pyIoropIasty: a solution to the management of bIeeding duodenal ulcer. Ann. Surg., 152: 416, 1960. 4. HOERR, S. O., DUNPHY, J. E. andGRAy, S. J. PIaceof surgery in emergency treatment of acute massive, upper gastrointestinal hemorrhage. Surg. Gynec. ti Obst., 87: 338, 194.8. 5. GRIFFITII, C. A. Gastric vagotomy vs. tota abdominal vagotomy. Arch. Surg., 81: 781, 1960. 6. BURGE, H. W. Vagotomv in the treatment of peptic ukeration. Post&aL G. J., 36: 2, 1960. _ _ 7. SCHNUG. G. E. and CAVANAGH. C. R. An anaIvsis of the morbidity and mortahty following gastric surgery for uIcer. Am. J. Surg., 104: 224, 1962.

395