The Effect of Parietal Cell Vagotomy and Selective Vagotomy with Pyloroplasty on Gastric ,4cid Secretion A Prospective Randomized Study ANDERS FAXBN & JAN KEWENTER Dept. of Surgery I1 and 111, Sahlgren’s Hospital, University of Goteborg, Goteborg, Sweden
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Faxen, A. & Kewenter. J. The effect of parietal cell vagotomy and selective vagotomy with pyloroplasty on gastric acid secretion. A prospec .ive randomized study. Scand J . Gastroent. 1978, 13, 815-820. The insulin- and pentagastrin-stimulated gastric acid secretion was studied before and 1 week, 1 month, 6 months and 1 year after parietal cell vagotomy (PCV)and selective vagotomy with pyloroplasty (SV + P) in 50 patients who,took part in a consecutive randomized trial. The randomization and the operations were performed in such a way that the extent of the denervation of the proximal stomach was identical in the two groups. Basal acid output and the insulin-stimulated acid secretion were significantly increased from 1 month to I year after PCV.while there was no such increaseafter SV + P.There was no change of the pentagastrin-stimulated acid sxretion (PAOP)from 6 to 12 months in either group. One year postoperatively PAOP was significantly greater after PCV than after SV + P.The results are compatible wii h vagal reinnervation after PCV and support the assumption of a sprouting from the innervated gastric antrum. Key-words: Duodenal ulcer; gastric acid secretion; vagotomy, parietal cell; vagotomy, selective A. F a x h , M.D., Dept. of Surgery, Centrallasarettet, BGX122,431 22 Molndal, Sweden
Since the introduction of highly selective vagotomy without drainage (parietal cell vagotomy, PCV) in the treatment of duodenal ulcer, several reports of the favourable results of this procedure have been published (3, 15). Although PCV has been compared with other types of vagotomy and gastric resection as regards the reduction of acid secretion (7, 13, 15), there are only two consecutive randomized trials in which PCV is compared with the other type of vagotomy strictly confined to the stomach, i.e. selective vagotomy with pyloroplasty (SV + P) (1 7, 19). No significant difference in acid secretion between the two operations was found in any of these studies. The recurrence rate was higher following PCV than following SV + P in Kronborg & Madsen’s study (1 7), and the incidence of positive Hollander tests was higher after PCV than after SV + P in Sawyer et al.’s series ( 19). The time interval between the tests and the operations was only 1 week in the first series (1 7), and in the second series only a part of the
patients were include,i in the postoperative acid secretion tests (I 9). The aim of the present investigation was to study both the insulin-stimL.lated and the pentagastrinstimulated acid secretion at regular time intervals after PCV and SV + P in a prospective randomized trial. In order to standardize the surgical technique, the performance of the two types of vagotomy was identical as regards the proximal dissection down to the angulus of the stomach. MATERIAL AND METHODS The study included 50 patients who were consecutively randomized for either of two elective operations for duodenal ulcer (6). Only patients under 60 years of age were included. All patients had had symptoms of duodenal ulcer for several years and at least two ulcers at eithe- gastroscopy or barium meal examination. Patients with signs of pyloric stenosis were not included. All patients were thoroughly informed of the study and had given their consent.
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816
A . Faxin 13J. Kewenter
There were 5 women and 20 men in each group. The median age in the PCV group was 4 1 (22-55) years and in the SV + P group 44 (23-56) years. All operations started with a parietal cell vagotomy as described by Amdrup & Jensen (2). Five to six centimetres of the distal oesophagus was skeletonized, and the lesser omentum, including the proximal branch of the ‘crow foot’, was sectioned along the lesser curvature. At this stage of the operation the code was broken and the patients were randomized. In patients randomized for SV + P the minor omentum, including the two nerves of Latarjet, was sectioned and ligated, and a two-layer 6 7-cm-long Heineke-Mikulicz pyloroplasty was made. In patients randomized for PCV the abdomen was closed immediately after the code was broken.
Gastric acid secretion tests Insulin tests were performed preoperatively and 1 week, 1 month, 6 months and 1 year after surgery, and pentagastrin tests were carried out preoperatively and 6 months and 1 year after operation. The patients came to the laboratory after fasting for 8 h. During the whole study the patients were sitting comfortably. A Salem Sump tube no. 14 was introduced via the nose or mouth, and its position was checked by aspiration and lavage several times. The tube was then connected to an intermittent pump (Egnell), and the gastric content was aspirated. The samples were titrated to pH 7.0 using 0.1 mol NaOH in an autoburette (Abu 12, Bergman and Beving). Basal acid secretion was measured during four 15-min periods before both insulin and pentagastrin stimulation. 0.2 IU Insulin Vitrumkg body weight was given intravenously, and the insulinstimulated acid secretion was collected and measured during 15-min periods for 2 h. Blood sugar levels were measured prior to the study and 30 and 45 min after the insulin injection. The insulin test was not accepted unless blood sugar levels reached below 2.2 mmol/l. The pentagastrin-stimulated secretion was measured during four 15-min periods following the injection of 0.6 pg pentagastridkg body weight (Peptavlon, 0.25 mg/ml, ICI). The two acid secretion tests were performed on separate days.
The results of the acid tests were presented as: BAO The mean of acid secretion during the hour prior to insulin and pentagastrin stimulation, respectively, or acid secretion during the basal hour prior to insulin injection (1 week and 1 month postoperatively). PA01 The sum of acid secretion during the two consecutive 15-min periods following insulin stimulation showing the highest acid output, multiplied by 2 and given in mmol/h. PAOP The corresponding calculation following pentagastrin stimulation. M A 0 k 0 Acid secretion during the first hour following insulin stimulation (mmol/h). MAOI12o Acid secretion during the second hour after insulin stimulation (mmolh). For the interpretation of the insulin-stimulated response seven criteria were used: Hollander (12), Ross 8z Kay (18), Bachrach (4), Stempien (20), Bank et al. (S), and Gillespie et al. (8). When two or more of the seven criteria were fulfilled, the test was considered positive. For the calculation of significance of differences within individuals the Wilcoxon test for pair difference was used, and in the comparisons between the two groups of patients the U-test of Mann-Whitney was used.
RESULTS Preoperatively there were no differences between the two groups of patients as regards acid secretion, basally or after stimulation. Table I shows acid secretion before and at various time intervals after PCV and SV + P respectively. The two groups of patients were well matched as regards both sex and age. One patient was lost from the 6- and 12-month tests in each group. One patient in each group had unpleasant side effects from the pentagastrin at the 6-month test and was therefore excluded from the I-year pentagastrin tests. Two patients had a recurrent duodenal ulcer during the first postoperative year, one in each group. They were included in all postoperative tests. Their test results did not influence the statistical significances of the differences between the two groups of operations studied.
Vagotomy with Pyloroplasty on Ga ptric Acid Secretion
817
Table I. Acid secretion (mmol/h. median and range. with mean values in parenthe:es) before and at various time intervals after parietal cell vagotomy (PCV) and selective vagotomy with pylorop1a:;ty (SV + P) respectively Postoperatively Preop.
1 week
I month
6 months
I year
PCV
3.3 (4.0) 0-0-11.8
1.1 (2.3) 0.0-14.3
0.5 (1.3) 0.0-6.7
1.0 (1.4) 0.0-5.4
1.2 (1.8) 0.0-8.2
sv + P
2.5 (3.2) 0.1-11.1
1.9 (2.7) 0.0-7.8
1.1 (1.4) 0.0-10.3
0.7 (1.1) 0.0-5.1
1.1 (1.5) 0.0-7.5
PC v
33.7 (35.4) 10.1-66.1
-
-
19.2 (18.7) 0.2-39.2
19.2 (21.1) I. 8-45.6
sv + P
30.0 (33.0) 17.4-59.9
-
-
13.5 (13.9) 0.1-2 1.9
10.2 (14.3) 0.1-3 1.8
PCV
28.1 (26.8) 6.0-52.8
1.7 (2.5) 0.0-1 8.8
2.1 (3.2) 0.0-14.1
5.2 (5.1) 0.0- 14.8
4.7 (5.9) 0.0-23.0
sv + P
26.0 (26.8) 9.9-50.9
1.8 (2.5) 0.0-9.2
1.2 (2.7) 0.0-10. 1
1.9 (2.8) 0.1-9.3
2.0 (3.5) 0.0-14.0
PC v
22.8 4.4-43.1
0.0 -6.3-1 6.0
1.1 -6.7-7.0
3.3 -0.7-1 1.9
2.7 -0.2-1 8.8
sv + P
22.2 6.6-45.3
-0.2 -3.0-4.3
- 1.1-8.3
1.0 -0.7-7.9
0.6 -2.0-7.3
PCV
14.0 0.9-23.2
0.2 0.0-4.5
0.3 0.0-3.2
0.4 0.0-5.7
0.0-6.7
sv + P
11.8 5.1-23.6
0.6 0.0-5.4
0.4 0.0-7.1
0.3 0.0-3.8
0.4 0.0-3.9
21.4 3.6-40.6
1.2 0.0-1 1.2
1.3 0.0-1 0.3
2.4 0.0-9.0
2.6 0.0-14.4
19.8 5.3-4 1.3
1.4 0.0-6.5
1.1
0.0-8.0
1.0 0.0-8.0
1.5 0.G7.2
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BAO
PAOP
PA01
PAOI-BAO 0.2
MA0160
Basal acid output (BAO) PCV. There was a significant decrease of RAO following PCV compared with preoperatively (p
Scand J Gastroenterol Downloaded from informahealthcare.com by McMaster University on 10/28/14 For personal use only.
Faxen, A. & Kewenter. J. The effect of parietal cell vagotomy and selective vagotomy with pyloroplasty on gastric acid secretion. A prospec .ive randomized study. Scand J . Gastroent. 1978, 13, 815-820. The insulin- and pentagastrin-stimulated gastric acid secretion was studied before and 1 week, 1 month, 6 months and 1 year after parietal cell vagotomy (PCV)and selective vagotomy with pyloroplasty (SV + P) in 50 patients who,took part in a consecutive randomized trial. The randomization and the operations were performed in such a way that the extent of the denervation of the proximal stomach was identical in the two groups. Basal acid output and the insulin-stimulated acid secretion were significantly increased from 1 month to I year after PCV.while there was no such increaseafter SV + P.There was no change of the pentagastrin-stimulated acid sxretion (PAOP)from 6 to 12 months in either group. One year postoperatively PAOP was significantly greater after PCV than after SV + P.The results are compatible wii h vagal reinnervation after PCV and support the assumption of a sprouting from the innervated gastric antrum. Key-words: Duodenal ulcer; gastric acid secretion; vagotomy, parietal cell; vagotomy, selective A. F a x h , M.D., Dept. of Surgery, Centrallasarettet, BGX122,431 22 Molndal, Sweden
Since the introduction of highly selective vagotomy without drainage (parietal cell vagotomy, PCV) in the treatment of duodenal ulcer, several reports of the favourable results of this procedure have been published (3, 15). Although PCV has been compared with other types of vagotomy and gastric resection as regards the reduction of acid secretion (7, 13, 15), there are only two consecutive randomized trials in which PCV is compared with the other type of vagotomy strictly confined to the stomach, i.e. selective vagotomy with pyloroplasty (SV + P) (1 7, 19). No significant difference in acid secretion between the two operations was found in any of these studies. The recurrence rate was higher following PCV than following SV + P in Kronborg & Madsen’s study (1 7), and the incidence of positive Hollander tests was higher after PCV than after SV + P in Sawyer et al.’s series ( 19). The time interval between the tests and the operations was only 1 week in the first series (1 7), and in the second series only a part of the
patients were include,i in the postoperative acid secretion tests (I 9). The aim of the present investigation was to study both the insulin-stimL.lated and the pentagastrinstimulated acid secretion at regular time intervals after PCV and SV + P in a prospective randomized trial. In order to standardize the surgical technique, the performance of the two types of vagotomy was identical as regards the proximal dissection down to the angulus of the stomach. MATERIAL AND METHODS The study included 50 patients who were consecutively randomized for either of two elective operations for duodenal ulcer (6). Only patients under 60 years of age were included. All patients had had symptoms of duodenal ulcer for several years and at least two ulcers at eithe- gastroscopy or barium meal examination. Patients with signs of pyloric stenosis were not included. All patients were thoroughly informed of the study and had given their consent.
Scand J Gastroenterol Downloaded from informahealthcare.com by McMaster University on 10/28/14 For personal use only.
816
A . Faxin 13J. Kewenter
There were 5 women and 20 men in each group. The median age in the PCV group was 4 1 (22-55) years and in the SV + P group 44 (23-56) years. All operations started with a parietal cell vagotomy as described by Amdrup & Jensen (2). Five to six centimetres of the distal oesophagus was skeletonized, and the lesser omentum, including the proximal branch of the ‘crow foot’, was sectioned along the lesser curvature. At this stage of the operation the code was broken and the patients were randomized. In patients randomized for SV + P the minor omentum, including the two nerves of Latarjet, was sectioned and ligated, and a two-layer 6 7-cm-long Heineke-Mikulicz pyloroplasty was made. In patients randomized for PCV the abdomen was closed immediately after the code was broken.
Gastric acid secretion tests Insulin tests were performed preoperatively and 1 week, 1 month, 6 months and 1 year after surgery, and pentagastrin tests were carried out preoperatively and 6 months and 1 year after operation. The patients came to the laboratory after fasting for 8 h. During the whole study the patients were sitting comfortably. A Salem Sump tube no. 14 was introduced via the nose or mouth, and its position was checked by aspiration and lavage several times. The tube was then connected to an intermittent pump (Egnell), and the gastric content was aspirated. The samples were titrated to pH 7.0 using 0.1 mol NaOH in an autoburette (Abu 12, Bergman and Beving). Basal acid secretion was measured during four 15-min periods before both insulin and pentagastrin stimulation. 0.2 IU Insulin Vitrumkg body weight was given intravenously, and the insulinstimulated acid secretion was collected and measured during 15-min periods for 2 h. Blood sugar levels were measured prior to the study and 30 and 45 min after the insulin injection. The insulin test was not accepted unless blood sugar levels reached below 2.2 mmol/l. The pentagastrin-stimulated secretion was measured during four 15-min periods following the injection of 0.6 pg pentagastridkg body weight (Peptavlon, 0.25 mg/ml, ICI). The two acid secretion tests were performed on separate days.
The results of the acid tests were presented as: BAO The mean of acid secretion during the hour prior to insulin and pentagastrin stimulation, respectively, or acid secretion during the basal hour prior to insulin injection (1 week and 1 month postoperatively). PA01 The sum of acid secretion during the two consecutive 15-min periods following insulin stimulation showing the highest acid output, multiplied by 2 and given in mmol/h. PAOP The corresponding calculation following pentagastrin stimulation. M A 0 k 0 Acid secretion during the first hour following insulin stimulation (mmol/h). MAOI12o Acid secretion during the second hour after insulin stimulation (mmolh). For the interpretation of the insulin-stimulated response seven criteria were used: Hollander (12), Ross 8z Kay (18), Bachrach (4), Stempien (20), Bank et al. (S), and Gillespie et al. (8). When two or more of the seven criteria were fulfilled, the test was considered positive. For the calculation of significance of differences within individuals the Wilcoxon test for pair difference was used, and in the comparisons between the two groups of patients the U-test of Mann-Whitney was used.
RESULTS Preoperatively there were no differences between the two groups of patients as regards acid secretion, basally or after stimulation. Table I shows acid secretion before and at various time intervals after PCV and SV + P respectively. The two groups of patients were well matched as regards both sex and age. One patient was lost from the 6- and 12-month tests in each group. One patient in each group had unpleasant side effects from the pentagastrin at the 6-month test and was therefore excluded from the I-year pentagastrin tests. Two patients had a recurrent duodenal ulcer during the first postoperative year, one in each group. They were included in all postoperative tests. Their test results did not influence the statistical significances of the differences between the two groups of operations studied.
Vagotomy with Pyloroplasty on Ga ptric Acid Secretion
817
Table I. Acid secretion (mmol/h. median and range. with mean values in parenthe:es) before and at various time intervals after parietal cell vagotomy (PCV) and selective vagotomy with pylorop1a:;ty (SV + P) respectively Postoperatively Preop.
1 week
I month
6 months
I year
PCV
3.3 (4.0) 0-0-11.8
1.1 (2.3) 0.0-14.3
0.5 (1.3) 0.0-6.7
1.0 (1.4) 0.0-5.4
1.2 (1.8) 0.0-8.2
sv + P
2.5 (3.2) 0.1-11.1
1.9 (2.7) 0.0-7.8
1.1 (1.4) 0.0-10.3
0.7 (1.1) 0.0-5.1
1.1 (1.5) 0.0-7.5
PC v
33.7 (35.4) 10.1-66.1
-
-
19.2 (18.7) 0.2-39.2
19.2 (21.1) I. 8-45.6
sv + P
30.0 (33.0) 17.4-59.9
-
-
13.5 (13.9) 0.1-2 1.9
10.2 (14.3) 0.1-3 1.8
PCV
28.1 (26.8) 6.0-52.8
1.7 (2.5) 0.0-1 8.8
2.1 (3.2) 0.0-14.1
5.2 (5.1) 0.0- 14.8
4.7 (5.9) 0.0-23.0
sv + P
26.0 (26.8) 9.9-50.9
1.8 (2.5) 0.0-9.2
1.2 (2.7) 0.0-10. 1
1.9 (2.8) 0.1-9.3
2.0 (3.5) 0.0-14.0
PC v
22.8 4.4-43.1
0.0 -6.3-1 6.0
1.1 -6.7-7.0
3.3 -0.7-1 1.9
2.7 -0.2-1 8.8
sv + P
22.2 6.6-45.3
-0.2 -3.0-4.3
- 1.1-8.3
1.0 -0.7-7.9
0.6 -2.0-7.3
PCV
14.0 0.9-23.2
0.2 0.0-4.5
0.3 0.0-3.2
0.4 0.0-5.7
0.0-6.7
sv + P
11.8 5.1-23.6
0.6 0.0-5.4
0.4 0.0-7.1
0.3 0.0-3.8
0.4 0.0-3.9
21.4 3.6-40.6
1.2 0.0-1 1.2
1.3 0.0-1 0.3
2.4 0.0-9.0
2.6 0.0-14.4
19.8 5.3-4 1.3
1.4 0.0-6.5
1.1
0.0-8.0
1.0 0.0-8.0
1.5 0.G7.2
Scand J Gastroenterol Downloaded from informahealthcare.com by McMaster University on 10/28/14 For personal use only.
BAO
PAOP
PA01
PAOI-BAO 0.2
MA0160
Basal acid output (BAO) PCV. There was a significant decrease of RAO following PCV compared with preoperatively (p
