Truncal
Vagotomy and Pyloroplasty for Duodenal Ulcer John R.
Two hundred sixty-five patients who underwent vagotomy and pyloroplasty for duodenal ulcer disease were observed postoperatively, 220 for two to ten years, with an average follow-up of five years. Vagotomy and pyloroplasty carried a higher overall recurrence rate (3.6%) than did subtotal gastrectomy and vagotomy (1%), largely because of the high ulcer recurrence rate more than two years after operation for massive bleeding (9.2%) rather than that following elective operation (1.8%). Thirty-five percent of these patients with recurrent ulcers did well with medical management and did not require a second operation. The mortality of vagotomy and pyloroplasty for a massively bleeding ulcer (11%) was less than that following subtotal gastrectomy (21%). The mortality of elective vagotomy and pyloroplasty was 1%.
Thereconcerning
continues to be divergence of surgical opinion the proper operation for medically uncon¬ trollable duodenal ulcer disease. Farmer et al1 in 1946 first popularized 50% gastrectomy (antrectomy) and vagotomy and pointed to the very low ulcer recurrence rate. Since their article appeared, many others have also accepted this operation for the complications of duodenal ulcer. Since that time, because of the long-term morbidity associated with subtotal gastrectomy, an equally large number of surgeons have performed various kinds of vagotomy with and without a drainage procedure.'-7 Enough time has passed to allow an accurate evaluation of the results of subtotal gastrectomy and vagotomy in regard to mortal¬ ity, morbidity, and recurrence rate.8" This operation has become standardized. The same cannot yet be said for various types of vagotomy and drainage or for superselective vagotomy done alone.1-'14 A sufficient period of time has not yet elapsed to allow us a totally definitive Accepted for publication Dec 26, 1974. From the Surgical Department, Harvard Medical School at the Peter Bent Brigham Hospital, Boston. Reprint requests to 721 Huntington Ave, Boston, MA 02115 (Dr. Brooks).
Brooks, MD; Dariush Kia, MD; Alejandro A. Membreno, MD
statement about end results.
However, truncal vagotomy and pyloroplasty has now been performed in large num¬ bers and these patients have been observed for long peri¬ ods of time.1517 Mortality and morbidity figures are avail¬ able for this operation, as well as recurrence figures for periods of time extending up to ten years.18"20 PATIENTS AND METHODS
During the years 1960 to 1971, approximately 325 vagotomies performed at the Peter Bent Brigham Hospital. Some of these were performed with gastrectomy for gastric ulcer; a few were performed with a Billroth II gastrectomy for duodenal ulcer when it was deemed impossible to perform a pyloroplasty due to the condition of the pylorus and duodenum. Some were performed for gastritis, for "stress ulcers" of the upper part of the stomach, and for the Mallory-Weiss syndrome. An occasional vagotomy was performed at the same time as a hiatus hernia repair. All other patients with uncontrollable duodenal ulcer disease ("intractability," obstruction, bleeding) underwent vagotomy and pyloroplasty. Two hundred sixty-five such operations were per¬ formed. No patients undergoing vagotomy and pyloroplasty for other than duodenal ulcer disease were included in this study. A subdiaphragmatic truncal vagotomy and pyloroplasty was per¬ formed in all cases. All patients were observed longer than two years. Contact was made with 94% of this group: by direct per¬ sonal interview, by communication with the patient's physician, by a recent report in the hospital record of an outpatient depart¬ ment visit, and, in the case of those at a distance, by direct tele¬ phone communication with the patient. Each patient was asked a standard group of questions. Those patients who appeared to have problems were asked to come to the hospital for direct interview and study. Those professing any significant digestive complaints in the upper part of the abdomen underwent gastrointestinal roentgenographic study. Several had gastroscopy performed. There were 189 men and 76 women in this group, ranging in age from 20 to 90 years. There were 90 patients over 60 years of age, 28 over 70, and 15 over 80. One hundred eighty-four (69.5%) of the patients were operated on because of "intractability" of the ulcer. General criteria of intractability of progressive, "virulent" duodewere
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/27/2015
Table
1.—Vagotomy-Pyloroplasty:
Elective Patients and Follow-Up 184 No. done 165 No. observed >2 yr 19 No. lost 3 Death or "failure" Death
Vagotomy and Pyloroplasty for Duodenal Ulcer John R.
Two hundred sixty-five patients who underwent vagotomy and pyloroplasty for duodenal ulcer disease were observed postoperatively, 220 for two to ten years, with an average follow-up of five years. Vagotomy and pyloroplasty carried a higher overall recurrence rate (3.6%) than did subtotal gastrectomy and vagotomy (1%), largely because of the high ulcer recurrence rate more than two years after operation for massive bleeding (9.2%) rather than that following elective operation (1.8%). Thirty-five percent of these patients with recurrent ulcers did well with medical management and did not require a second operation. The mortality of vagotomy and pyloroplasty for a massively bleeding ulcer (11%) was less than that following subtotal gastrectomy (21%). The mortality of elective vagotomy and pyloroplasty was 1%.
Thereconcerning
continues to be divergence of surgical opinion the proper operation for medically uncon¬ trollable duodenal ulcer disease. Farmer et al1 in 1946 first popularized 50% gastrectomy (antrectomy) and vagotomy and pointed to the very low ulcer recurrence rate. Since their article appeared, many others have also accepted this operation for the complications of duodenal ulcer. Since that time, because of the long-term morbidity associated with subtotal gastrectomy, an equally large number of surgeons have performed various kinds of vagotomy with and without a drainage procedure.'-7 Enough time has passed to allow an accurate evaluation of the results of subtotal gastrectomy and vagotomy in regard to mortal¬ ity, morbidity, and recurrence rate.8" This operation has become standardized. The same cannot yet be said for various types of vagotomy and drainage or for superselective vagotomy done alone.1-'14 A sufficient period of time has not yet elapsed to allow us a totally definitive Accepted for publication Dec 26, 1974. From the Surgical Department, Harvard Medical School at the Peter Bent Brigham Hospital, Boston. Reprint requests to 721 Huntington Ave, Boston, MA 02115 (Dr. Brooks).
Brooks, MD; Dariush Kia, MD; Alejandro A. Membreno, MD
statement about end results.
However, truncal vagotomy and pyloroplasty has now been performed in large num¬ bers and these patients have been observed for long peri¬ ods of time.1517 Mortality and morbidity figures are avail¬ able for this operation, as well as recurrence figures for periods of time extending up to ten years.18"20 PATIENTS AND METHODS
During the years 1960 to 1971, approximately 325 vagotomies performed at the Peter Bent Brigham Hospital. Some of these were performed with gastrectomy for gastric ulcer; a few were performed with a Billroth II gastrectomy for duodenal ulcer when it was deemed impossible to perform a pyloroplasty due to the condition of the pylorus and duodenum. Some were performed for gastritis, for "stress ulcers" of the upper part of the stomach, and for the Mallory-Weiss syndrome. An occasional vagotomy was performed at the same time as a hiatus hernia repair. All other patients with uncontrollable duodenal ulcer disease ("intractability," obstruction, bleeding) underwent vagotomy and pyloroplasty. Two hundred sixty-five such operations were per¬ formed. No patients undergoing vagotomy and pyloroplasty for other than duodenal ulcer disease were included in this study. A subdiaphragmatic truncal vagotomy and pyloroplasty was per¬ formed in all cases. All patients were observed longer than two years. Contact was made with 94% of this group: by direct per¬ sonal interview, by communication with the patient's physician, by a recent report in the hospital record of an outpatient depart¬ ment visit, and, in the case of those at a distance, by direct tele¬ phone communication with the patient. Each patient was asked a standard group of questions. Those patients who appeared to have problems were asked to come to the hospital for direct interview and study. Those professing any significant digestive complaints in the upper part of the abdomen underwent gastrointestinal roentgenographic study. Several had gastroscopy performed. There were 189 men and 76 women in this group, ranging in age from 20 to 90 years. There were 90 patients over 60 years of age, 28 over 70, and 15 over 80. One hundred eighty-four (69.5%) of the patients were operated on because of "intractability" of the ulcer. General criteria of intractability of progressive, "virulent" duodewere
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/27/2015
Table
1.—Vagotomy-Pyloroplasty:
Elective Patients and Follow-Up 184 No. done 165 No. observed >2 yr 19 No. lost 3 Death or "failure" Death
