Correspondence Hill CL, Barker MCS. Anterior highly selective vagotomy with posterior truncal vagotomy: a simple technique for denervating the parietal cell mass. Br J Surg 1978;65: 602-5. Taylor TV, Holt S, Heading RC. Gastric emptying after anterior lesser curve seromyotomy and posterior truncal vagotomy. Br J Sury 1985;72: 620-2. Mouiel J, Katkhouda N. Laparoscopic truncal and selective vagotomy. In: Zucker KA, Bailey RW, Reddick EJ, eds. Surgical Laparoscopy. St Louis: Quality Medical Publishing, 1991 : 263-79.
Laparoscopic vagotomy: a new tool in the management of duodenal ulcer disease Sir
Medical therapy has dominated the treatment of uncomplicated peptic ulcer disease for the past 15 years. We occasionally encounter patients with intractable ulcer diathesis who prefer to have an operation rather than face life-long medication. In this group, the advent of minimally invasive laparoscopic vagotomy may provide an alternative to expensive long-term treatment with H, antagonists or acid-blockers. Twelve such patients were offered laparoscopic vagotomy between May 1991 and March 1992.The indication in all cases was intractable disease characterized by multiple relapses despite long-term H, antagonist therapy (mean 4 (range 2-10) years). The mean age was 39 (range 27-51) years; ten were men and two women. The mean (range) preoperative basal acid output (BAO) and peak acid output ( P A O ) were 14.6 (4.2-20.5)and47.4(36.1-65.1)rnmol/hrespectively. Six patients underwent posterior truncal vagotomy with anterior highly selective vagotomy, three had bilateral truncal vagotomy with endoscopic dilatation of the pylorus, and two underwent posterior truncal vagotomy with anterior seromyotomy. The last patient had bilateral truncal vagotomy and gastrojejunostomy performed laparoscopically for pyloric stenosis complicating ulcer disease. These techniques have been proven in open surgery to be effective in reducing acid output'-3. The choice of the type of vagotomy depended on the configuration of the anterior vagal trunk and its branches. The mean duration of the operation was 150 (range 120-210)min. After operation, feeding was resumed on the third day and patients discharged on the fourth. There were no major complications. One patient who underwent posterior truncal vagotomy and anterior highly selective vagotomy had poor gastric emptying requiring endoscopic pyloric dilatation. The mean (range) postoperative BAO and P A 0 were 4.1 (3.1-7.3) and 16.5 (2.6-25.7)mmol/h, respectively. This minimally invasive procedure is safe and associated with little postoperative discomfort, a shorter convalescence and good cosmesis. Larger series with Long-term follow-up are required to test the efficacy of this approach, but early experience suggests that laparoscopic vagotomy may provide the solution for the group of patients with chronic intractable ulcer d i a t h e s d . C. K. Kum P. Coh Department of Surgery Nafional University Hospiral Lower Kent Ridge Road Singapore 051 1 1.
Taylor TV, Macleod DAD, Gunn AA et a/. Anterior lesser curve setomyotomy and posterior truncal vagotomy in the treatment of chronic ulcer disease. Lancet 1982;ii: 846-9.
Br. J. Surg., Vol. 79, No. 9. September 1992
Predeposit autologous blood transfusion in patients w i t h colorectal cancer: a feasibility study Sir
In their recent article (Br J Surg 1992; 79: 355-7) Harrison and colleagues have utilized autologous donation as an ingenious device to circumvent the ethical difficulties of studying the effects of transfusion on patients with colorectal cancer. Unfortunately, in their prospective study they have come to the same conclusion as we arrived at in a recent retrospective analysis of blood use in a general surgical context', namely that the operations they were performing did not use blood on a sufficient scale to justify the effort of autologous donation. We analysed all general surgical operations and found that very few would be suitable for the offer of autologous donation, on the basis of the average quantity of blood transfused. However, within general surgery the operations of abdominoperineal resection of the rectum and gastrectorny would be suitable, because of broadly predictable transfusion requirements. While most units will not perform sufficient numbers of these procedures to justify the setting up of an autologous donor service, other surgical specialties carry out operations where blood loss is predictably high, such as transurethral surgery or hip replacement. If autologous donation is to become feasible in general surgery, we must cooperate with other surgical specialties t o achieve cost effectiveness. Perhaps this would also allow the elucidation of the nature of the effect of transfusion on survival. B. Jaffray University Department of Surgery Glasgow Royal InJirmary Alexundra Parade Glasgow G4 OSF
UK 1.
Jaffray B, King PK, Basheer AMM, Gillon J. Efficiency of blood use in general surgery and prospects for autologous donor schemes. Ann R Coll Surg Engl 1991;13: 235-7.
977
Laparoscopic vagotomy: a new tool in the management of duodenal ulcer disease Sir
Medical therapy has dominated the treatment of uncomplicated peptic ulcer disease for the past 15 years. We occasionally encounter patients with intractable ulcer diathesis who prefer to have an operation rather than face life-long medication. In this group, the advent of minimally invasive laparoscopic vagotomy may provide an alternative to expensive long-term treatment with H, antagonists or acid-blockers. Twelve such patients were offered laparoscopic vagotomy between May 1991 and March 1992.The indication in all cases was intractable disease characterized by multiple relapses despite long-term H, antagonist therapy (mean 4 (range 2-10) years). The mean age was 39 (range 27-51) years; ten were men and two women. The mean (range) preoperative basal acid output (BAO) and peak acid output ( P A O ) were 14.6 (4.2-20.5)and47.4(36.1-65.1)rnmol/hrespectively. Six patients underwent posterior truncal vagotomy with anterior highly selective vagotomy, three had bilateral truncal vagotomy with endoscopic dilatation of the pylorus, and two underwent posterior truncal vagotomy with anterior seromyotomy. The last patient had bilateral truncal vagotomy and gastrojejunostomy performed laparoscopically for pyloric stenosis complicating ulcer disease. These techniques have been proven in open surgery to be effective in reducing acid output'-3. The choice of the type of vagotomy depended on the configuration of the anterior vagal trunk and its branches. The mean duration of the operation was 150 (range 120-210)min. After operation, feeding was resumed on the third day and patients discharged on the fourth. There were no major complications. One patient who underwent posterior truncal vagotomy and anterior highly selective vagotomy had poor gastric emptying requiring endoscopic pyloric dilatation. The mean (range) postoperative BAO and P A 0 were 4.1 (3.1-7.3) and 16.5 (2.6-25.7)mmol/h, respectively. This minimally invasive procedure is safe and associated with little postoperative discomfort, a shorter convalescence and good cosmesis. Larger series with Long-term follow-up are required to test the efficacy of this approach, but early experience suggests that laparoscopic vagotomy may provide the solution for the group of patients with chronic intractable ulcer d i a t h e s d . C. K. Kum P. Coh Department of Surgery Nafional University Hospiral Lower Kent Ridge Road Singapore 051 1 1.
Taylor TV, Macleod DAD, Gunn AA et a/. Anterior lesser curve setomyotomy and posterior truncal vagotomy in the treatment of chronic ulcer disease. Lancet 1982;ii: 846-9.
Br. J. Surg., Vol. 79, No. 9. September 1992
Predeposit autologous blood transfusion in patients w i t h colorectal cancer: a feasibility study Sir
In their recent article (Br J Surg 1992; 79: 355-7) Harrison and colleagues have utilized autologous donation as an ingenious device to circumvent the ethical difficulties of studying the effects of transfusion on patients with colorectal cancer. Unfortunately, in their prospective study they have come to the same conclusion as we arrived at in a recent retrospective analysis of blood use in a general surgical context', namely that the operations they were performing did not use blood on a sufficient scale to justify the effort of autologous donation. We analysed all general surgical operations and found that very few would be suitable for the offer of autologous donation, on the basis of the average quantity of blood transfused. However, within general surgery the operations of abdominoperineal resection of the rectum and gastrectorny would be suitable, because of broadly predictable transfusion requirements. While most units will not perform sufficient numbers of these procedures to justify the setting up of an autologous donor service, other surgical specialties carry out operations where blood loss is predictably high, such as transurethral surgery or hip replacement. If autologous donation is to become feasible in general surgery, we must cooperate with other surgical specialties t o achieve cost effectiveness. Perhaps this would also allow the elucidation of the nature of the effect of transfusion on survival. B. Jaffray University Department of Surgery Glasgow Royal InJirmary Alexundra Parade Glasgow G4 OSF
UK 1.
Jaffray B, King PK, Basheer AMM, Gillon J. Efficiency of blood use in general surgery and prospects for autologous donor schemes. Ann R Coll Surg Engl 1991;13: 235-7.
977
