A Prospective Study of Parietal Cell Vagotomy and Selective Vagotomy-antrectomy for Treatment of Duodenal Ulcer PAUL H. JORDAN, JR., M.D.

A prospective, randomized, study involving 92 patients who required elective operation for treatment of duodenal ulcer was performed to compare the results of Parietal Cell Vagotomy (PCV) and selective vagotomy-antrectomy Billroth I (SV-A-BI). The protocol was broken twice. One patient was unable to undergo PCV because of pyloric stenosis and one patient underwent Billroth II anastomosis instead of Billroth I because of post-bulbar stenosis. Performance of PCV was never aborted because a patient was obese. There were no deaths. Diarrhea, dumping and other gastric complaints were less frequenct after PCV than after SV-A-BI for all time periods studies up to two years. Two months after operation, the Hollander tests were negative in 59% of patients after PCV and in 100% after SV-A-BI. Inhibition of BAO and MAO were also significantly less after PCV than after SV-A-BI. Since vagotomy of the parietal cell mass was identical in both groups of patients it was concluded that the differences in the secretory rates and the fewer negative Hollander tests in the PCV group than in the SV-A-BI group were due to retention of the antrum irrespective of its innervation. There was no explanation for the gradual increase in the BAO in the PCV group. One recurrent ulcer occurred in the PCV group in a patient who overindulged in alcohol and aspirin. After 4 days of medical management, this superficial ulcer healed as demonstrated by endoscopy. There were no recurrent ulcers after SV-A-BI. As a result of this study, it is concluded that PCV is superior to SV-A-BI because of the lower frequency of postoperative complications, diarrhea, dumping and other symptoms associated with gastric surgery. PCV may be the operation of choice for the elective treatment of duodenal ulcer; however, it remains undetermined whether the recurrent ulcer rate following PCV will be sufficiently low that the procedure can retain a position of superiority over SV-A-BI.

From the Surgical Services of the Cora and Webb Mading Department of Surgery, Baylor College of Medicine and the Veterans Administration Hospital, Houston, Texas

GRIFFITH AND HARKINS4 recognized that ablation of the pyloric sphincter contributed significantly to the

undesirable sequelae of gastric surgery. They studied, in dogs, the possibility of performing a vagotomy of the acid secreting portion of the stomach which at the same time preserved the innervation of the antrum so that destruction or bypass of the sphincter to permit gastric emptying was unnecessary. This logical concept lay fallow until Holle7 first performed in man Selective Proximale Vagotomie which he combined with pyloroplasty. The full potential of Griffith and Harkins'4 proposal was not realized clinically until Johnston10 reported that patients undergoing highly selective vagotomy did not require a drainage procedure so long as the pyloric lumen was not severely compromised by fibrosis and obstruction. Subsequently this operation was performed by many surgeons and the results obtained by those authors2'18 with the greatest experience have been excellent. In comparison with other gastric procedures dumping and diarrhea were reduced in frequency and severity and the number of persistent or recurrent ulcers was astonishingly low. Other authors16'21 with fewer patients reported an alarming number of recurrent ulcers but as their experience increased, the frequency of recurrent ulcers Presented at the Annual Meeting of the Southern Surgical Associ- decreased. 17,22 ation, December 8-10, 1975, The Homestead, Hot Springs, Virginia. The attractive physiological features of parietal cell All correspondence to: Paul H. Jordan, Jr., M.D., 1200 Moursund and the good results obtained by Johnston10 vagotomy Avenue, Houston, Texas 77025. 619

JORDAN

620 TABLE 1. Preoperative Data Pertaining to Ulcer Patients

PCV SV-A-B, (N = 45) (N = 47)

Duration of Ulcer Symptoms (Years) Patients with history of bleeding Patients requiring transfusions Patients with previous perforation Patients with UGI Roentgenograms Those + for ulcer crater Those suggestive of ulcer Number of Patients Gastroscoped Gastroscopy + for ulcer Gastroscopy suggestive for ulcer + =

10 ± 7 17 6 4

13

+

7

19 3 42 23 19 31 28 3

10 47 23 23 31 28 2

Standard deviation

and Amdrup1 encouraged us to perform a pilot study to determine whether, in our hands, the operation warranted a prospective, randomized evaluation. The early results that were obtained in 35 patients demonstrated that the operation could be performed in the majority of patients treated for intractability." On the basis of the good early results obtained in that study a prospective, randomized study was initiated to compare parietal cell vagotomy without drainage (PCV) and selective vagotomy, antrectomy and Billroth I anastomosis (SV-A-BI). This operation was chosen for comparison because the frequency of postoperative, gastric, sequelae associated with its use was no greater than with other procedures and the number of recurrent ulcers was less than with any other procedure. Patients and Methods Ninety-two consecutive patients requiring elective operation for duodenal ulcer were studied. Cases accrued to the study between April, 1973 and October, 1975. No patient with known obstruction or active bleeding was entered into the study. The operation to be performed was selected randomly prior to opening the abdomen. It was necessary to deviate twice from the operation selected. One patient underwent a resection and a Billroth II anastomosis instead of PCV because the pylorus was deemed too constricted. In one patient, a Billroth II anastomosis was performed because it was considered a safer procedure than a Billroth I anastomosis. The operations actually performed were PCV in 45, SV-A-BI in 45 and SV-A-BII in two patients. Three patients undergoing SV-A-BI had stomal dysfunction and required gastroenterostomy. All patients were symptomatic at the time of operation. Although duodenal ulcer disease was the principle indication for operation, additional operative procedures performed at the time of PCV included splenectomy in 4 patients, appendectomy in 10, hiatal herniorrhaphy in 2, left hepatectomy in 1, aorto bilateral-femoral by-pass graft in one and gastrotomy in 7 patients to verify the

Ann. Surg. o June 1976

existence of a duodenal ulcer. The pylorus was narrowed in two patients but was adequately dilated in one patient to permit PCV without drainage. In the second patient it was necessary to perform resection instead of PCV. There was marked periduodenal inflammation present in 17 patients and 6 patients were very obese. in the patients undergoing SV-A-BI, splenectomy was performed in 3 patients and appendectomy in 8. The pylorus in 3 patients assigned to this operation would have been too small to permit PCV had this operation been selected. There was marked periduodenal induration and inflammation present in 9 patients. The duration of ulcer disease prior to operation and the number of patients with a history of bleeding or previous perforation are presented in Table 1. Although some patients were bleeding when admitted to the hospital, none was bleeding at the time of operation and all were able to undergo gastric analysis. An ulcer crater was demonstrated in 52% of 89 patients studied roentgenographically and in 90% of 62 patients examined gastroscopically. The author participated in all operations reported in this study. The technique of PCV employed was similar to that previously published.12 The junction between the fundic and pyloric gland areas of the stomach was located by noting where the main terminal branch of the anterior nerve of Latarjet approached the lesser curvature of the stomach. This point averaged 6 cm from the pylorus. The main vagal trunks were isolated with tapes because gentle traction on these tapes facilitated the dissection and helped to avoid injury to the nerves of Latarjet. The lesser curvature was then devascularized from the antral-fundal junction to the esophagogastric junction. The esophagus was completely encircled in order to facilitate its inspection and section of all vagal branches to the stomach. The terminal esophagus was mobilized and anything suggestive of a nerve structure that appeared to come from the main vagal trunks and was supplying the distal 4 cm of esophagus was cut. The operation was completed by performing reperitonealization of the lesser curvature of the stomach and suturing the phrenoesophageal ligament attached to the

esophagogastric junction to the diaphragm. In those patients undergoing antrectomy vagotomy was done exactly as in those patients who had PCV

alone. It was by this means that the size of the antrum was estimated. After vagotomy the antrum was resected using the line between innervated and denervated stomach as the line of transection. The portion of stomach removed was not more than 20% of the stomach and was smaller than our estimate of the antrum in previous studies. The lesser curvature of the stomach was closed and a gastroduodenostomy performed. The proximal margin of the specimen was consistent with

Vol. 183 . No. 6

621

STUDY OF PARIETAL CELL VAGOTOMY

the transitional zone or of the antrum but not of the fundic area. Gastric secretory studies were performed preoperatively and at 2, 6, 12 and 24 months postoperatively on those patients who would consent. The technique for the secretory studies was previously reported.11 Maximal acid output (MAO) was stimulated by the administration of 1.2 mg of Histalog (Betazole) per kg. Gastric juice was collected in 15 minute periods for two hours. The insulin acid output (IAO) was performed by administration of 0.2 u per kg of regular insulin. Gastric juice was collected in 15 minute periods for two hours. In the basal period (BAO) preceding each test gastric juice was collected for four consecutive 30 minute periods. An aliquot of each collection of gastric juice was titrated with 0.1 N sodium hydroxide to pH 7.3 and the total two hour acid output for each test calculated. The acid secretion for the first and second hours after insulin stimulation was calculated also. Hollander's6 criteria for interpretation of the test were applied to each hourly sample, to determine if the insulin test was early or late positive. The peak hourly basal, Histalog and insulin stimulated acid outputs were also expressed as PAOB, PAOH and PAOQ, respectively. These values were determined by taking the two successive 15 minute periods showing the highest acid output in the respective tests and multiplying by two. Gastric analyses performed preoperatively were of limited value in establishing a diagnosis or in making the decision whether or not to operate. Very high basal acid output suggested on several occasions the coexistence of a gastrinoma. In these patients, the effects of the calcium challenge and the secretin challenge tests on acid secretion and serum gastrin levels were studied. A gastrinoma was not identified in any patient. Efforts were made to readmit patients to the hospital for studies and interview at 2, 6, 12 and 24 months. In addition to a standard set of questions asked at each time period by the author, any suggestive response was pursued in depth. Many of the patients were also interviewed at one year by an independent physician. Upper gastrointestinal roentgenograms were made prior to discharge from the hospital after operation and at the time of study two months after operation. Subsequently, roentgenograms were made only in those patients who had retention of barium at the time of the previous examination or in whom it seemed clinically indicated. Patients underwent gastroscopy whenever they had any gastric complaints that at all resembled recurrent ulcer. A provocative dumping test was performed by administration of 250 ml of ½2 and ½2 cream and milk and 100 ml of 50% dextrose. A nasogastric tube was placed into the stomach to test for overnight gastric residual

TABLE 2. Major Complications Associated with Operation Number of Patients

Complication

PCV

SV-A-B,

Wound infection Stomal dysfunction Reoperation for stomal dysfunction Reoperation for intestinal obstruction Average days hospitalized postop Hospitalization longer than 10 days postop Two hour gastric retention of barium at discharge Two hour barium retention at 2 months

2 1 0 2* 10 + 3 11

3 7 3 2t 13 ± 8 25

11/44 4/41

25/46 8/39

One at 10 days and one 6 months after PCV t Both at 12 months after SV-A-B, ± = Standard deviation *

and before it was removed, the "dumping cocktail" was introduced through the tube without the patient knowing what was given. The patients were then observed for two hours and changes in pulse rate and blood pressure, the occurrence of flushing, sweating, headache, borborygmi and the urge to defecate were recorded at 15 minute intervals. This test was performed in 13 patients in whom there was a question of dumping. The method of grading the clinical results was a simplification of the Visick grading system proposed by Kennedy14; I no symptoms, II mild but not troublesome symptoms, III more severe symptoms with some disability, IV disabling symptoms or recurrent ulcer. Results Immediate Postoperative Results: There were no operative deaths in the study. After PCV the nasogastric tube was usually removed the day of or the day after operation and feedings were started by the third day. Removal of the nasogastric tube and resumption of feeding were delayed by several days after antrectomy. The average number of hospital days required after PCV and SV-A-BI were 10 and 13, respectively. Early postoperative complications related to operative technique are summarized in Table 2. There were no anastomotic leaks recognized. Seven patients had stomal dysfunction after SV-A-BI. None of these patients had an associated febrile episode to suggest infection or abscess and only one patient had a second procedure (appendectomy) done at the first operation. Three of the 7 patients required reoperation. The anastomoses were patent but had failed to function properly because of surrounding fat necrosis. This was due to pancreatitis in one patient in whom the resection and the anastomosis had been difficult. A gastrojejunostomy was performed in each of these three patients with complications. One of these patients was subsequently reoperated for small bowel obstruction. The

JORDAN

622 TABLE 3. Patients A vailable for Study Months Postop

Operation PCV

SV-A-B,

Patients

Preop

2

6

12

24

Interviewed Studied Interviewed Studied

45 45 47 47

41 39 42 38

34 32 33 29

27 24 26 17

12 12 13 9

induration surrounding the Billroth I anastomosis had completely disappeared. Initially one patient had prolonged gastric retention after PCV. The pylorus was widely patent on gastroscopy but gastric motility was diminished. This problem disappeared within two months and was attributed to possible injury to the anterior vagus nerve. Two patients required reoperation for intestinal obstruction after PCV and two after SV-A-BI. No patient in the PCV group required reoperation for pyloric obstruction. Late Followup Studies: The number of patients interviewed and who consented to study at the various time periods after operation appear in Table 3. Of the PCV patients, two died at one year and one at two years. After SV-A-BI, one patient each died at 6, 12 and 24 months. No death was related to duodenal ulcer disease or to the operation. The postoperative gastrointestinal complaints elicited from patients are tabulated in Table 4. Abdominal discomfort referred to symptoms that might suggest recurrent ulcer including distension, gas and any other nondescript symptoms. Because of these symptoms, 6 patients underwent gastroscopy after PCV and one patient after SV-A-BI. Evidence of a recurrent ulcer was noted at one year in one patient after PCV. Many patients acknowledged early satiety and mild dysphagia during the first postoperative month TABLE 4. Postoperative Gastrointestinal Symptoms

SV-A-B,

PCV Months 2

Number of Patients Studied

Symptoms Early satiety Early dumping Late dumping Dysphagia Nausea

6

Months

12 24

41 34 27 12 2 6 1 3 1 0 0 2 2

1 6 1 1 0 0 0 0

0 2 0 2 0 0 2 0 1

Vomiting Epigastric discomfort Diarrhea 0 Reflux Number of Patients Without 25 25 20 Symptoms

2

6

0 2 0 0 0 0 2 0 1

4 13

0 8 3 0 0 0 2 2 1

0 7 1 1 0 0 0 1 1

8

20 19 15

6

4

3 0 0 0 3 1

Surg. * June 1976

after both operations but these complaints had greatly diminished by the second month. The frequency of dumping was greatest two months after operation and occurred in 15% of patients after PCV and 31% after SV-A-BI. Of the patients with early dumping at two months who were studied for two years, dumping persisted throughout that period in 2 of 4 patients with PCV and in 4 of 6 patients after SV-A-BI. Dumping was not incapacitating for any patient but it was ofgreater magnitude after SV-A-BI than after PCV. Dumping that occurred after PCV could be easily controlled by the elimination of milk, chocolate or high carbohydrate foods. The dumping test was performed with negative results in one of the two patients with dumping after PCV. It was performed in 4 of 6 patients with persistent dumping after SV-A-BI. The test was positive in each of these 4 patients and resulted in tachycardia, nausea, flushing and passage of a loose bowel movement. At two months diarrhea, unrelated to dumping, occurred in two patients with PCV but was continuous in neither patient after that time. After SV-A-BI, three patients had diarrhea at two months but it persisted throughout the study in only one patient. The severity of diarrhea was also greater after SV-A-BI than after PCV; however, it was not disabling or of serious consequence for any patient. Secretory Studies: Table 5 shows the range of acid recovered during the two hour preoperative basal secretory tests. The number of patients secreting at different rates were distributed approximately equally in the two groups; although, there were more of the very low secretors in the PCV group and more of the very high secretors in the SV-A-BI group. Table 6 shows the change in secretory rates with time and the per cent that the secretory rates at the various time periods were inhibited when compared with the preoperative secretory rates. After SV-A-BI, all secretory parameters were inhibited in excess of 85% at all time periods when compared with the values for the same parameters measured preoperatively. The results after PCV were quite different. With time, there was a steady rise in the basal and

12 24

42 33 26 13 3 8 3 0 2 2 1 3 0

Ann.

TABLE 5. Preoperative Basal Secretory Rates Per cent Patients

mEq HCI Per 2 Hr

PCV

SV-A-B,

0- 2 2.1- 4 4.1- 6 6.1- 8 8.1-10 10.1-20 >20

11 18 12 16 20 16 7

6 21 21 19 6 11 15

VOl. 183 . NO. 6

STUDY OF PARIETAL CELL VAGOTOMY

623

TABLE 6. Results of Gastric Secretory Studies

SV-A-B,

PCV Months Postop

Mean PAOB mEq/hr Mean PAOH mEq/hr Mean PAO, mEq/hr % Reduction: PAOB PAOH

Preop

2

6

12

24

Preop

2

6

12

24

6.1

1.2

1.9

2.5

2.3

7.2

0.2

0.4

0.3

0.4

44.9

16.4

15.9

18.7

16.8

42.4

4.9

5.1

3.8

3.4

34.9

2.2

3.2

4.6

4.6

35.8

0.2

0.1

0.5

0.3

81 ±34 60±16 86 ± 8

63±29 63±17 89 ± 8

55±40 51±15

53±24 54±15

98±7 88±8

86±28 86±15

97±4 90±7

95±3 92±3

87 ± 11

88 ± 3

99 ± 1

99 ± 1

99 ± 1

99 ± 1

8.3

1.5

2.6

3.3

4.0

9.6

0.2

0.4

0.4

0.3

72.1

24.6

25.6

29.7

30.4

69.0

6.3

6.3

5.1

3.5

45.6

2.6

2.4

6.1

6.4

44.8

0.1

0.6

0.4

0.3

81 ± 28 64 ± 17 89± 9

67 33 63 18 88 14

56 ± 35 57 ± 19 87+ 7

44 ± 30 55 ± 17 89± 6

10 10 99± 1

92 ± 25 88 ± 12 99± 1

97 ± 5 92 ± 6 98± 1

92 ± 4 94 ± 4 99±2

39

32

24

12

38

29

17

9

PAO, Mean BAO mEq/2 hr Mean MAO mEq/2 hr Mean IAO mEq/2 hr % Reduction: BAO MAO IAO Patients Tested

Months Postop

45

95 90

47

± = Standard deviation

maximal acid secretory parameters so that after two years basal and maximal acid outputs were approximately 50% of the preoperative values. At two years the inhibition of BAO was significantly (P < 0.05) less than it had been at two months. There was no other significant difference in the degree of inhibition between any two time periods for any of the secretory parameters. Inhibition of the acid response to insulin was more persistent and was 80% at two years compared with 86 to 89% at two months. After PCV the per cent of patients with a negative insulin test decreased from 59% at two months to 33% at 24 months (Table 7) although the acid secretory response to insulin was inhibited nearly the same at both time periods (Table 6). By contrast, the acid response to insulin after SV-A-BI was almost completely inhibited at two months and remained so throughout the two years. After SV-A-BI all patients had a negative insulin test at two months and there was little indication of a decreasing number of negative tests with time. At all time periods, the per cent of patients who had returned to full employment was greater after PCV than after SV-A-BI (Table 8). The postoperative work record of those patients undergoing PCV was better than those who had SV-A-BI even when one considered that more patients in the PCV group were working preoperatively. Table 9 shows the changes in the patients' weight compared with their preoperative weight. At each time interval the per cent of patients who equaled or exceeded

their preoperative weight was greater after PCV than after SV-A-BI. Evaluation of Patients Recurrent Ulcers: The one recurrent ulcer that developed in the study occurred in a man 12 months after PCV. He had been well until Christmas when he imbibed heavily in alcohol and aspirin. He complained of epigastric pain and gastroscopy confirmed a small superficial duodenal ulcer. His insulin test was positive. The patient was treated medically and when he was regastroscoped 4 days later the ulcer had healed. The patient has been without symptoms for a year. No patient was a possible suspect for recurrent ulcer at the time of this report. The grading of the clinical results is seen in Table 10. While both operations provided overall good results, 4% of patients at one year had results that fell outside of the excellent or good categories following PCV and 15% had TABLE 7. Results of the Hollander Tests

SV-A-B1

PCV Months Postop

Months Postop

Number of Tests

2

6

12

24

2

6

12

24

Negative Early Positive Late Positive

23 6 10

13 9 11

4 12 8

4 6 2

38 0 0

27 0 1

15 0 2

9 0 0

JORDAN

624 TABLE 8. Work Status of Patients After Operation

SV-A-B,

PCV Months Postop 2

Preop

Full Time Part Time No Work Per cent Working Full Time

6

Months Postop Preop

12 24

2

6

12 24

32 1 12

14 23 21 3 2 1 24 9 5

8 1 3

29 2 16

9 18 15 3 3 1 28 12 10

5 1 7

71

34 68 78 67

62

23 55 58 38

results that failed to achieve the excellent or good categories after SV-A-BI. If one considered the shorter postoperative recovery time, fewer significant complications and an intangible sense of well-being manifested by work and weight status associated with PCV, the difference between the two operations might be greater than the results of the Visick grading indicated. Discussion Parietal cell vagotomy without a drainage procedure has been practiced for nearly 8 years. The reported results of the operation have been generally enthusiastic although a few early reports on small numbers of patients provided a cautious warning regarding the overzealous adoption of the operation. This paper confirms the favorable reports and suggests that for at least two years PCV is equally as effective as SV-A-BI in the prevention of recurrent ulcer and is superior to that operation with respect to the fewer postoperative complications and gastric sequelae that occur. The severity of the duodenal ulcer diathesis was nearly equal in both groups of patients in terms of symptomatology, acid secretion and existing pathology. Preoperative verification of duodenal ulcer was significantly more accurate when made by endoscopy using the flexible gastroscope than by roentgenograms. This method of examination was a valuable tool not only for diagnosis but for postoperative evaluation of patients' symptoms. TABLE 9. Weight Change in Patients After Operation

SV-A-B,

PCV Months Postop

No. of Pats.

2

6

12 24

2

6

12

24

40

34

26 12 6

42 6

30 5

24 6

12 2

8 8 5 Weight = Preop Weight ± 6.6 Kg 11 13 9 < Preop Weight 22(5)* 17(3)* 7 Per cent Equaled or Exceeded 50 73 45 Preop Weight

> Preop

*

Months Postop

2 4

1 2 9 9 27(7)* 16(3)* 16(3)* 9(1)*

67

Number of patients below ideal weight

36

47

33

25

Ann.

Surg. * June 1976

Therefore, endoscopy must be easily accessible to the surgeons trained in its use. It is no more logical for the gastroenterological surgeon to be denied the use of this diagnostic modality than it would be for the thoracic surgeon to be restricted in the use of the bronchoscope. It has been stated that PCV is a time consuming operation and that its application is limited, particularly in obese patients. In the average patient, the time required for PCV equaled that for truncal vagotomy and pyloroplasty. We were able to perform PCV in 45 of 46 patients assigned this operation for elective treatment of duodenal ulcer irrespective of the fact that 6 were extremely obese. In the one patient in whom PCV was not performed, the pylorus was considered too constricted and unsuitable for dilatation. The operation does require a longer time and is more difficult when the patient is obese. One can obviously perform truncal vagotomy with greater facility in these patients and it is always an option that is open to the surgeon. However, to persist with PCV in a difficult patient must be based on the surgeon's conviction that PCV provides an advantage to the patient. Then it will not be difficult for him to spend the extra time and effort required to perform the operation correctly. In fact, if the surgeon has not been convinced of its merits, he should not embark on PCV. During the first two postoperative months, gastric retention of ingested barium after SV-A-BI was greater than after PCV. The degree of barium retention noted after SV-A-BI was unexpected since we had never performed upper gastrointestinal roentgenograms routinely in the early postoperative period before. Whether this finding was of clinical importance is doubtful since the patients did not complain of retention with the same frequency and by the sixth month roentgenograms failed to demonstrate retention. It is of interest, however, that 7 of 13 patients with early dumping during the first two months after SV-A-BI and 2 of 6 patients following PCV also had early barium retention. The explanation for greater barium retention after SV-A-BI than after PCV was probably related to stomal function rather than stomal patency for a number of patients with retention were gastroscoped and the stomas were completely patent. Three patients, however, were reoperated and a gastroenterostomy performed because of stomal dysfunction and external compression by a sterile inflammatory mass. These patients might not have required reoperation had we been willing to wait longer for the anastomosis to function. This was suggested in 2 of the 3 patients by the subsequent roentgenograms that demonstrated gastric emptying through the gastroduodenostomy as well as the gastrojejunostomy. This study confirmed previous reports showing that the incidence of dumping2.8 was less after PCV than after

Vol. 183oNo. 6

STUDY OF PARIETAL CELL VAGOTOMY

other operations in which the pylorus was by-passed or destroyed. At the two month followup period dumping occurred in 15% of patients after PCV and 31% after SV-A-BI. At one year dumping had decreased to 7% in patients with PCV but remained at 3 1% in those who had SV-A-BI. Dumping after PCV was always mild and could be easily avoided by the elimination of a particular item from the diet, usually sweet milk. Buttermilk or a small amount of sweet milk on cereal and in cooking was tolerable. Drinking a glass of sweet milk, however, would cause dumping. Since liquids leave the stomach more quickly than normal after PCV the problem arising with milk may be due to the rapid exodus of milk from the stomach and a relative lactase deficiency.19 Dumping after SV-A-BI was usually more difficult to control than after PCV and was a serious problem in one patient. In several retired patients dumping would have created a greater problem had they been working for then it would have been difficult or impossible for them to lie down after eating. As in other studies,2 9 diarrhea occurred infrequently after PCV. Two months after PCV diarrhea was present in two patients but persisted in neither. After SV-A-BI diarrhea was present in three patients at two months and persisted in the one patient who has been followed for two years. Of particular interest are two patients who had previously had a right colon resection. The bowel pattern in the patient undergoing PCV was only slightly altered from what it had been preoperatively; however, the bowel movements of the patient who underwent SV-A-BI increased in frequency and were of a watery consistency. The difference between these two patients suggested that the preservation of the pyloric sphincter was of particular benefit to the patient in whom the ileocecal valve had also been lost. The results of this study were too premature to draw conclusion concerning the relative frequency with which recurrent ulcers will develop after the two operations. The only recurrent ulcer after either operation occurred one year after PCV as a complication of alcohol and aspirin ingestion. After 4 days on medical treatment, endoscopy demonstrated that the ulcer had healed. A satisfactory reduction in BAO or MAO was not achieved in this patient and the insulin test had changed from a late to early positive. The patient demonstrated that while the secretory response after PCV was sufficiently reduced to permit healing of an ulcer, the operation did not protect the stomach or duodenum from the abuse of excessive ingestion of alcohol and/or aspirin. Under these stresses, the stomach, capable of acid production after PCV, is subject to the development of a peptic ulcer as might occur in anyone. Although recurrent ulcers after PCV have been reported as low as 2%,215 the persistence of a significant basal acid secretion reported

625

TABLE 10. Evaluation of Clinical Results Per cent Visick

Months Postop

Patients Studied

I

II III IV

PCV

Patients and Author

2 6 12 24

41 34 27 12

39 30 23 9

2 4 3 3

0 0 0 0

0 0 1 0

SV-A-B,

Independent Observer

SV-A-B,

2 6 12 24 12 12

42 33 26 13 24 20

31 25 16 8 18 13

8 8 6 4 6 7

3 0 4 0 0 0

0 0 0 1 0 0

Evaluator

Operation

PCV

by others3 and our observation that it increased with time gives us concern that the recurrence rate after PCV may increase. The decreased secretory response to insulin and the fewer patients with a positive Hollander test after SVA-BI than after PCV could be attributed to compensation for incomplete vagotomy of the parietal cell mass by antrectomy. If this was the explanation, why should the insulin response and the number of positive Hollander tests increase with time after PCV but not after SV-A-BI? These observations might be explained by reinnervation of the parietal cell mass. Since the vagotomy of the parietal cell mass was identical in both groups of patients, one would have to assume that reinnervation of the parietal cell mass occurred via the retained vagal fibers to the antrum. The marked differences in the acid secretory rates after the two types of operation leave one with the inescapable conclusion that the explanation is related to the retention of the antrum or its innervation in one group and not the other. Similar differences in acid secretory rates were observed after truncal vagotomy, antrectomy and Billroth I and truncal vagotomy and pyloroplasty. 13 It is, therefore, our opinion that the differences noted in the secretory patterns between SV-A-BI and PCV were due to retention of the antrum rather than retention of its innervation. One can speculate that the greater response to insulin after PCV than after SV-A-BI was due to a non-vagal effect of insulin, perhaps the effect of insulin released catecholamines on gastrin release.5'20 This does not explain, however, why the basal secretory response after PCV increased with time. The hypothesis that there is reinnervation of the parietal cells which makes them more sensitive to gastrin from the retained antrum remains a possibility. Prospective studies performed to evaluate different operations for the treatment of duodenal ulcer have shown that, with the exception of an increased number of recurrent ulcers after vagotomy and drainage operations,

JORDAN

626

there has been a surprising similarity in the frequency of gastric symptoms observed in patients who have undergone different operations. Our study showed that it was technically possible to perform PCV in 95% of patients undergoing elective operation. The early symptomatic results of SV-A-BI were good but those following PCV were better. The question to be answered before PCV can be recommended for general use without reservations is whether the recurrent ulcer rate after 5 to 10 years will fall within an acceptable level. While this study did not contribute to the final answer to that question, our results along with others were encouraging in a negative way since recurrent ulcers did not develop as a problem during the period that the patients were studied. References 1. Amdrup, E. and Jensen, H.-E.: Selective Vagotomy of the Partietal Cell Mass Preserving Innervation of the Undrained Antrum: A Preliminary Report of Results in Patients with Duodenal Ulcer. Gastroenterology, 59:522, 1970. 2. Amdrup, E., Jensen H.-E., Johnston, D., et al.: Clinical Results of Parietal Cell Vagotomy (Highly Selective Vagotomy) Two to Four Years after Operation. Ann. Surg., 180:279, 1974. 3. Greenall, M. J., Lyndon, P. J., Goligher, J. C. and Johnston, D.: Long Term Effect of Highly Selective Vagotomy on Basal and Maximal Acid Output in Man. Gastroenterology, 68:1421, 1975. 4. Griffith, C. A. and Harkins, H. N.: Partial Gastric Vagotomy: An Experimental Study. Gastroenterology, 32:96, 1957. 5. Hayes, J. R., Ardill, J., Kennedy, T. L., et al.: Stimulation of Gastrin Release by Catecholamines. Lancet, 1:819, 1972. 6. Hollander, F.: Laboratory Procedures in the Study of Vagotomy (With Particular Reference to the Insulin Test). Gastroenterology, 11:419, 1948. 7. Holle, F. and Hart, W.: Neue Wege der Chirurgie des Gastroduodenalulkus. Med. Klin., 62:441, 1967.

DISCUSSION

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8. Humphrey, C. S., Johnston, D., Walker, B. E., et al.: Incidence of Dumping after Truncal and Selective Vagotomy with Pyloroplasty and Highly Selective Vagotomy without Drainage Procedure. Br. Med. J., 3:785, 1972. 9. Johnston, D., Humphrey, C. S., Walker, B. E., et al.: Vagotomy without Diarrhoea. Br. Med. J., 3:788, 1972. 10. Johnston, D. and Wilkinson, A. R.: Selective Vagotomy with Innervated Antrum without Drainage Procedure for Duodenal Ulcer. Br. J. Surg., 56:626, 1969. 11. Jordan, P. H., Jr.: Parietal Cell Vagotomy without Drainage: Early Evaluation of Results in the Treatment of Duodenal Ulcer. Arch. Surg., 108:434, 1974. 12. Jordan, P. H., Jr.: Early Results of Parietal Cell Vagotomy without Drainage in the Treatment of Duodenal Ulcer. Tex. Med., 70:83, 1974. 13. Jordan, P. H., Jr. and Condon, R. E.: A Prospective Evaluation of Vagotomy-Pyloroplasty and Vagotomy-Antrectomy for Treatment of Duodenal Ulcer. Ann. Surg., 172:547, 1970. 14. Kennedy, T., Connell, A. M., Love, A. H. G., et al.: Selective or Truncal Vagotomy: Five-Year Results of a Double-Blind, Randomized, Controlled Trial. Br. J. Surg., 60:944, 1973. 15. Kennedy, T., Johnston, G. W., MacRae, K. D. and Spencer, E. F. A.: Proximal Gastric Vagotomy: Interim Results of a Randomized Controlled Trial. Br. Med. J., 2:301, 1975. 16. Kronborg, 0. and Madsen, P.: A Controlled, Randomized Trial of Highly Selective Vagotomy Versus Selective Vagotomy and Pyloroplasty in the Treatment of Duodenal Ulcer. Gut, 16:268, 1975. 17. Kronborg, O.: Personal Communication. 18. Moberg, S. and Hedenstedt, S.: Clinical, Secretory and Motor Effects of Selective Proximal Vagotomy. A Three-Year FollowUp. Acta. Chir. Scand., 141:203, 1975. 19. Pirk, F., Skala, I. and Vulterinova, M.: Milk Intolerance after Gastrectomy. Digestion, 9:130, 1973. 20. Stadil, F. and Rehfeld, J. F.: Gastrin Response to Insulin after Selective, Highly Selective and Truncal Vagotomy. Gastroenterology, 66:7, 1974. 21. Wastell, C., Colin, J. F., MacNaughton, J. I. and Gleeson, J.: Selective Proximal Vagotomy with and without Pyloroplasty. Br. Med. J., 1:28, 1972. 22. Wastell, C., Wilson, T. and Pigott, H.: Proximal Gastric Vagotomy. Proc. Roy. Soc. Med., 67:1183, 1974.

DR. THOMAS BOMBECK (Chicago): I rise to discuss this paper as of those people who has had one of these small series, which we have been brash enough to present early on. That's especially significant in view of the results of this particular series. This is one of the very few and possibly the first very good randomized series of this operation which demonstrates a good, acceptable result. I would first like to address myself to the possible reasons for that. (Slide) This slide was first presented a year ago at the Surgical Forum. It demonstrates the results of basal and augmented, or augmented histamine and basal secretory studies in patients with parietal cell vagotomy alone, selective vagotomy-antrectomy, and truncal vagotomy, studied preoperatively, six weeks postoperatively, and one year postoperatively. The dashes here represent patients with parietal cell vagotomy. This demonstrated exactly the same sort of result that Dr. Jordan and others have presented that parietal cell vagotomy does not result in gastric secretory levels although it results in an early fall. The basal and the augmented histamine secretory levels do recover, although in his series they did not recover to anywhere near preoperative levels. In our series they did. This was presented on 14 patients in the parietal cell vagotomy series, and at that time we had two recurrent ulcers. That was an incidence of approximately 14%. Other authors doing randomized series, Amdrup with 8%, Wastell with 16%, Kronborg with 22% in their early randomized series, had suggested that perhaps it was pre-

one

DR. EDWARD R. WOODWARD (Gainesville, Florida): We share Dr. Jordan's guarded enthusiasm for this procedure, and have used it both in a series of randomized patients, in association with three other southem universities, and also have used it in selected cases-those I call the disaster-prone patients. This, in general, is the white, middle-aged female with intractable duodenal ulcer. In our early experience, we discovered in Chicago that in the first 500 cases women accounted for only 10% of the operations, but they accounted for 50% of the bad results. In this particular group we have found PCV to be delightfully well accepted, and very pleasantly free of postoperative sequelae. We had difficulty in mastering the technique until one of us visited Leeds and watched Goligher and Johnston operate. They use what my house staff refer to as the "automatic intern," and I can recommend this for any parahiatal surgery. This is a subxiphoid retractor attached to a rigid standard on the edge of the table, with the patient then put in reverse Trendelenburg. This flattens out the diaphragm, makes exposure at the e.g. junction much easier, and even, to some extent, straightens out the lesser curvature, making dissection of these tiny fibers under direct vision much easier. We have had in 25 patients one recurrent duodenal ulcer. I would like to ask Dr. Jordan how to overcome the difficulties in the surgical management of recurrence after this operative procedure.

Ann. Surg.

A porspective study of parietal cell vagotomy and selective vagotomy-antrectomy for treatment of duodenal ulcer.

A Prospective Study of Parietal Cell Vagotomy and Selective Vagotomy-antrectomy for Treatment of Duodenal Ulcer PAUL H. JORDAN, JR., M.D. A prospecti...
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