Vagotomy and Double Pyloroplasty for Peptic Ulcer JAMES R. HINES, M.D., ROBERT E. GEURKINK, M.D., THOMAS A. KORNMESSER, M.D., LARRY WIKHOLM, M.D., ROBERT P. DAVIS, M.D.

Seventy patients with peptic ulcers (55 duodenal and 15 gastric) From the Department of Surgery, Northwestern were treated by truncal vagotomy and double pyloroplasty durUniversity Medical School, 251 East Chicago Avenue, ing the past four years. Clinical and experimental data as Chicago, Illinois 60611 presented lead us to believe that transecting the pylorus twice produces an incontinent pyloric sphincter and a larger gastric outlet than is found in other methods of pyloroplasty. This earned an increasing popularity. Vagotomy with pyloroplasty decreases gastric stasis and has led to a lower ulcer recurrence has become the most widely used primary surgical treatrate (1.5%). In addition, the untoward postoperative sequelae ment in peptic ulcer disease.30 48 The major obstacle to the are minimal. The 70 patients treated (for the most part consecutive cases) exhibited the usual complications of peptic ulcer general acceptance of this procedure has been a distressdisease. Thirty-three had intractable pain, 23 bleeding (15 ingly high ulcer recurrence rate of 4-27%. In addition, the massive), 13 obstruction, and one acute perforation. There were unpleasant side effects of dumping, diarrhea, and failure to no operative or postoperative deaths and the only serious gain weight have not been eliminated.18'19'26'31'42'56 postoperative complication was unrelated to the double The cauises for recurrent ulcer following vagotomy and pyloroplasty. During the followup period four patients have include gastric stasis due to inadequate drainage drainage died of unrelated diseases. Of the remaining 66 patients one incomplete vagotomy, and undiagnosed procedures, ulcer which has responda recurrent peptic developed probable ed to medical management. Four patients have intermittent Zollinger-Ellison tumors.30 A wide variety of gastric outlet dumping, three have mild diarrhea and one has failed to gain procedures, such as the Weinberg modification of the weight, Constipation and weight gain are more common com- Heineke-Mikulicz pyloroplasty, the Finney pyloroplasty, plaints. It would appear that vagotomy with double pyloroplasty is a safe and effective operation for peptic ulcers and that further and the Jaboulay gastroduodenostomy have been used in an attempt to improve gastric emptying. Selective vagotomy clinical trials are warranted.

117 E FEEL that most failures (following vagotomy and VVpyloroplasty for peptic ulcer) are due to poorly emptying pyloroplasty. If you have a stomach that does not empty, you are in trotible ... and so is the patient!" (Jack M. Farris, commenting on Hoerr and Ward.27) While attending a lecture on rectal surgery, one of us (J. H.) was again impressed by the admonition that the anal sphincter can be safely transected once buit that double transection leads to rectal incontinence. This led to the speculation that double transection of the pyloric sphincter might be utilized to produce pyloric incontinence as an adjunct to pyloroplasty, hopefully to improve gastric emptying. A wide variety of surgical procedures have been advocated for the treatment of peptic ulcer disease during the past 25 years. Operations that preserve gastric tissue have Stibmitted for ptiblication April 22, 1974.

has many advocates who feel that it affords a more complete vagotomy than truncal vagotomy. In this procedure the nerves to the stomach are divided while the nerves to the other viscera are preserved. It is usuially accompanied by an ouitlet procedure. Highly selective (parietal cell mass) vagotomy has also been used. In this procedure the parietal cell mass of the stomach is deprived of its vagal innervation, while the nerves of Laterjet, the nerves to the antrum, and the remaining vagus nerves are preserved. The pyloric sphincter remains functional so that an outlet procedure is usually not needed. Recent studies of patients that have had parietal cell mass vagotomy indicate that over a period of two or three years there may be some parasympathetic regrowth as the insulin and histamine stimulation tests tend to show an increased response."° The Zollinger-Ellison Syndrome is now more frequently recognized as there is increased awareness of its hypersecretion, hyperacidity, and elevated serui-m gastrin levels. Ouir personal observations have led tus to believe that the

40

VAGOTOMY AND DOUBLE PYLOROPLASTY

V,,l. 181 * No. I

high recuirrence rates observed following vagotomy and gastric ouitlet operations are usuially related to a poorly functioning gastric ouitlet procedure. Even the single layer Weinberg modification of the Heineke-Mikulicz has been shown to result in gastric stasis.30' 3940'65 We have developed a new gastric outlet operation that has greatly improved gastric emptying. It is the purpose of this paper to describe the rationale of this procedure and to report the results of early clinical trials. Background Gastric Innervation The sympathetic innervation of the stomach is throuigh the paired T5 through T1o sympathetic ganglia via the greater and lesser splanchnics, the celiac plexus, and the right and left celiac and the superior mesenteric ganglia. The post ganglionic fibers are conveyed to the stomach alongside the celiac and superior mesenteric arteries. Historically, the removal of the sympathetic ganglia (as in the Smithwick operation for hypertension) caused parasympathetic overbalance with gastric hyperacidity, hyperperistalsis, and pyloric relaxation. These patients had an unuisually large number of peptic ulcers. The ulcers were almost always painless, the primary symptoms being bleeding, perforation, or obstruction. A complete vagotomy (in the presence of intact sympathetics) results in a sympathetic overbalance with hypoacidity, gastric atony and hypertonicity of the pyloric sphincter. Removing the vagal innervation of the stomach resuilts in two defects: the loss of the antral pump and pylorospasm. As far as the remainder of the intestine is concerned, a complete vagectomy should result in constipation, not diarrhea. It is possible that "post-vagotomy" diarrhea may be due to incomplete vagectomy and with overstimulation of the remaining fibers of the vagus. It is our impression that a complete truincal vagotomy at the esophago gastric jtunction not only produces anacidity but uisually leaves the patient with either normal stools or somewhat constipated. We have continued to perform truncal or "total" vagotomy and have directed ouit investigational efforts toward an improved gastric ouitlet procedure. We designed studies to see if the pyloric sphincter becomes incontinent when transected twice, and to determine how this affects gastric emptying.

41

Dog Experiments Twelve healthy, large aduilt mongrel dogs were kept on a standard laboratory diet and received the usuial inocuilations. Fotur dogs were used as controls. Four dogs had a bilateral truincal vagotomy and a Weinberg modification of the Heineke-Mikulicz pyloroplasty. In the remaining fouir dogs a back wall pyloric transection was added to the vagotomy and Weinberg pyloroplasty (Fig. 1). Gastric emptying times were sttudied two months after the operation by feeding the dogs a mixtuire of 60 gm of barium sulfate, 200 gm of canned dog food and 50 cc of water and taking hourly films tuntil the stomach was empty. The emptying times in all three of these grouips were not statistically different, having 75% emptying in 5-51/2 hours and complete emptying in 7-71/2 houirs. (We shouild have repeated these emptying stuidies at longer periods following operation, as later huiman stuidies showed that after a year patients with a double pyloroplasty emptied better). The eight dogs with vagotomy and pyloroplasty were re-operated at four months. The animals with a double pyloroplasty had an "incontinent" sphincter, as it did not completely close on stimuilation. The pyloric openings were then measured by a modification of a "ring-sizer" dilator. On modest pressure the dogs with a double pyloroplasty had a 25% larger gastric ouitlet. On maximal pressure, the size of the openings in the

;t~ ~

Experimental Studies Cadaver Studies Stuidies were carried out on ten cadavers. We found that the posterior aspect of the human pylorus could be transected without endangering the common bile duct, the pancreas, or other vital structuires. Even in patients with scarring from peptic ulcer disease the posterior sphincter could be safely transected.

Fi(;. 1. Method of transection of the posterior pyloric muscle.

42

Aiiii.

HINES AND OTHERS

grouips were abouit the same, the difference being related to the size of the animal. None of the dogs had gross evidence of gastritis from duiodenal refluix, but microscopic sections were not stuidied. All of the dogs tolerated the operations withouit difficuilty.

two

Clinical Studies Duiring the past fouir years we have operated upon 70 patients for peptic uilcer disease uising a truincal vagotomy and a douible pyloroplasty. We made no attempt to eliminate diffictult or complicated cases, the 70 cases being consecuitive cases operated for both duiodenal and gastric tilcers, except in those few cases that pathologic process made the proceduire technically impossible. These include delayed perforations, severe inflammatory response, necrotic tissuie, or the inability to rule ouit gastric carcinoma. We have not uised this proceduire in patients with "stress" uilcers.

Operative Technique Vagotomy. The bilateral truincal vagotomy was carried ouit at the esophago-gastric junction, being careful to transect all fibers entering the stomach. Special care was taken to transect a common left lateral branch of the left vaguis as it enters the top of the stomach. No attempt was made to preserve any vagal fibers, thuis producing a "total" vagotomy. We avoided dissection at the esophagealdiaphragmatic hiattus as we feel that damage to the phrenico-esophageal ligament can lead to reflux esophagitis and at times to iatrogenic hiatuis hernia.

Double Pyloroplasty. This techniquie was first described by one of uis (J.H.) in Suirg. Gynecol. Obstet. in July, 1971. It consists of the Weinberg modification of the HeinekeMikuilicz pyloroplasty with the addition of a posterior wall transection of the circular pyloric muscle (Fig. 1). After transecting the posterior pyloric muiscle, the mucosa and suibmuicosa were closed. A Kocher maneuver was carried out in order to close the anterior suture line without stress. Throuigh the anterior pyloromyotomy gastric ulcers were biopsied and actively bleeding ulcers oversewn. In patients with post-builbar stenosis the opening on the gastric side was made near the pylortus and the opening on the duodenal side was carried down to a point distal to the stenotic area. Post-builbar stenosis was easily treated by this method. The index finger was introduiced into the duiodenuim in all cases to eliminate the possibility of post-bulbar duodenal stenosis.

Siirg. jantiary -

1975

eight were males and 21 were females. Fifty-one were white, 18 black, and one Oriental. The duration of symptoms was from 2 days to 38 years, and the average duration was 81/2 years. Eighteen patients had seriouis associated medical illnesses; diabetes, pulmonary disease, alcoholism and druig abuise being among the most common of these diseases. Location of Ulcers Fifty-five patients had duodenal ulcers and 15 gastric ulcers. Of the 55 duiodenal ulcers 48 were in the bulbar region and seven were in the post-bulbar area causing post-bulbar stenosis. Of the gastric uilcers two were multiple, fouir were pre-pyloric or channel uilcers and the remaining nine were single gastric ulcerations of varying size. All patients with gastric uilcers had gastroscopy with biopsy of the ulcers as well as repeated biopsies at the time of the operation. None of the patients with gastric ulcers has developed a carcinoma, has had an overlooked carcinoma, or has failed to heal. Improved gastroscopy with biopsy has been especially helpfuil in establishing the correct diagnosis prior to the operation (Table 1). Reason for Operation

Thirty-three of ouir patients were operated upon for intractable pain, 23 for bleeding, 13 for obstruction, and one for acuite perforation. Of the 33 patients operated primarily for pain, eight also had bleeding episodes. Seven of those patients also had severe weight loss. Of the 23 patients operated tupon for bleeding, 11 were operated upon during an acuite massive hemorrhage and had the bleeding point oversewn. Fouir were operated upon after the acute massive hemorrhage had stopped. Massive bleeding is arbitrarily described as bleeding that requires replacement of 2,000 ml of blood in 24 houirs or 3,500 ml in 72 hours. Eight patients were operated uipon for repeated hemorrhages. Of the 13 patients operated upon for obstruction, three were obstrtucted from recent perforation, two were obstructed from acuite channel uilcers, and the remaining six had progressive obstruiction from old scar tissue. We were somewhat reluictant to use this procedure in patients with obstruiction buit early success encouraged its use. One patient with an acuite perforated duodenal ulcer was treated by vagotomy and double pyloroplasty (Table 2). TABLE 1. Location of Ulcers

Patient Population All 70 patients

(70 Patients)

operated upon in the Wesley Pavilion of the Northwestern Memorial Hospital, a 650-bed private practice hospital associated with Northwestern University Medical School. Fifty-two patients were private patients and 18 were service or clinic patients. The ages varied 17-73 years and the average age was 48 years. Fortywere

55

Dtiodenal Btilbar Post-bulbar

48 7

Single M ultiple Pre-pyloric

9 2 4

15

Gastric or

Channel

Volx. 181

* NO.

VAGOTOMY AND DOUBLE PYLOROPLASTY

I

TABILE 2. Reason for Operation (70 Patients) Pain

Bleeding

Massive

Obstruction

Repeated Chronic Acute (Acute)

Perforation

15 8 7 6

33 23 13 1

Preoperative Evaluation Most of the patients operated

upon had basal acid stludies, response to insulin and histamine, gastric volume stuidies, and tipper G. I. exams. In the case of actite bleeding or in gastric uilcers, gastroscopy, biopsy, and at times, angiography were performed. During the past few years endoscopy has become about 90% accurate compared to an average of 75% in tipper gastrointestinal X-rays. The combination of both stuidies gives excellent results.

Results of Clinical Studies Intraoperative Problems Vagotomy. The complications of this procedure are usually minimal. Esophageal damage is rare but temporary

dysphagia has been reported to be as high as 5%."4 This may have. played a role in a patient that developed esophageal obstrtiction from a bolus of meat. Two patients in otir series reqtiired splenectomy becatise of capsular bleeding. Pyloroplasty. We have had no sututre line difficulties ing the Weinberg modification of the Heineke-Mikulicz pyloroplasty in some 200 cases in otir personal series. In addition, we have had no problems related to the posterior wall procedtire in the 70 cases reported in this series. We feel that the Kocher maneuver reduces the stress on the stittire line and is of valtie. Multiple Procedures. In the current series we have performed gastric biopsy in 11 patients, oversewing the bleeding areas in 11 patients, cholecystectomy in six patients, and repair of a hiattis hernia in two patients. tis-

Immediate Postoperative Period Becatise of the Weinberg clostire there is often some postoperative bleeding from the mucosal margin; this rarely exceeds 200 ml and tistially stops within 12 hours. Ten patients developed atelectasis which responded promptly to treatment. Two patients, both of whom had chronic obstrtictive pulmonary disease, developed pneumonitis. One patient developed gastric atony which reqtiired a nasogastric ttibe for eight days, one patient had an ileus that reqtiired decompression for 12 days, and one patient had a partial small bowel obstrtiction that needed decompression for 14 days. One patient swallowed an unchewed bolus of meat which caused an incomplete obstruction at the esophago-gastric junction. An attempt at extraction on the

43 12th postoperative day resulted in esophageal perforation that required both abdominal and thoracic drainage and six weeks of postoperative hospitalization. She eventually made a complete and total recovery and is without symptoms. Three patients developed urinary tract problems that responded to treatment. Five patients developed superficial would infections, and the organisms cultured would indicate their origin to be the patient's skin or the nasopharynx of the operating team. Because of the larger opening produced by the double pyloroplasty, the nasogastric suction was usually removed 2448 hours after operation. We feel that the early removal helped to reduce puilmonary problems and encouraged early ambulation.43 Feeding of liquids was usually started on the third or fourth day. Most patients were discharged on the seventh or eighth postop day. Long Term Postoperative Followup The method of postoperative evaluation was by individaul person-to-person interview. The patients were given ample opportunity to discuss their symptoms or related problems. All of the patients were followed. The average period of followup was 22 months. Seven patients had mild diarrhea that persisted for three months and then stopped. Three other patients continue to have at least one loose stool a day, but the diarrhea is not debilitating. Five patients complain of constipation and in one patient this has been a serious problem. One patient had lost weight preoperatively from 170 to 135 pounds. For the next 18 months he was unable to gain weight. He finally gained to 160 only to develop a squamous cell carcinoma in his neck and back down to 120 pounds. This is the only patient who failed to thrive. Weight gain, not weight loss, became a common problem, as serious obesity has developed in four patients. Seven patients described the "dumping syndrome" of post-cibal epigastric distress, palpitation, and sweating, these symptoms being relieved by lying down. In three patients this has disappeared but it has persisted more than a year in four others. In most of these patients it is sporadic and is partially relieved by eating dry meals. All of the 13 patients operated upon for obstruction were carefully followed with upper gastrointestinal X-rays. None of these patients has re-obstructed. One patient with a huge stomach required seven months before his stomach returned to a normal size as seen in serial gastrointestinal studies. During this period he was symptomless. Onp patient was seen a year after having been operated upon for obstruction with the complaint of two black stools following a weekend of excessive alcoholic intake. She recovered without treatment and was thought to have had alcoholic gastritis, but this could not be documented as she refused examination or treatment. One patient developed epigastric pains 2% years after his operation. Six months later a stomach X-ray demonstrated a possible pre-pyloric antral recurrence, but

Ann. Stirg. * jantiary 1975 HINES AND OTHERS 44 this was not confirmed by gastroscopy. He was put on uindesirable side effects have urged surgeons to seek other medical management and has been symptomless for six procedures.17'31'62 Truncal vagotomy with antrectomy has a months. While otur period of followup is short (6 months to low operative mortality and morbidity rate, a low rate of 31/3 years), Hoerr & Ward report that recurrent ulceration disabling side effects and a very low rate of recurrence. It severe enouigh to require another operation usuially is the procedure of choice for a large number of sur-

manifests itself within three years.27'57 The other untoward geons 18,19,25,31,42,47,50,56,65 Selective vagotomy with antrecproblems uisuially appear immediately after surgery, tomy has many advocates who feel that this procedure proand only infrequiently later on" (Table 3). duces a more complete vagotomy with fewer untoward postpostop

operative sequelae and

Postoperative Studies Thirty-seven patients in this series had

a

lower

recurrence

rate.22'32'33'36'52'53

Other authors feel that there is little difference between the upper G.I. X-rays results obtained between selective and truncal vagotomy operatheir following years two to weeks taken from two and that selective vagotomy must be approached with Radiologically studied. were times tion. One-houir emptying cauition. 10,283135,38,44,55,59 pyloroplasty double a with patients it wouild appear that Truncal vagotomy with gastrojejunostomy is employed Weinberg the with have a larger opening than patients infrequently because the postoperative diarrhea, dumping Within pyloroplasty. modification of the Heineke-Miktilicz and recurrence rates are high.2'20'52'f6f°4 Its use now is gastric the operation, the first few months following the usuially confined to those few cases in which there is a same the marked inflammatory response that precludes other operaemptying times following barium meal were about were times in both grouips. However, when emptying tions. stuidied a year or more after operation, the patients with Truncal vagotomy with pyloroplasty is currently the most than readily douible pyloroplasty appeared to empty more widely used procedure in patients with duodenal peptic those with a single pyloroplasty. ulcers. The ease of performance gives it a low operative morbidity and mortality. The untoward postoperative Deaths sequelae is minimal, and the recurrence rate is acceptable, Fouir patients have died since having had a vagotomy and although higher than with vagotomy and antrectomy.18' 1925' douible pyloroplasty; however, the deaths were not related 31,42,56 Vagotomy and pyloroplasty has recently been reported to be satisfactory in patients with obstructing to the operation or to peptic ulcer disease. duodenal ulcers.9 Some authors feel that this procedure Current Status of Patients can cause an abnormally rapid emptying time which leads to Of the 66 surviving patients, only one had developed diarrhea or dumping.6'7'29 33,45 Selective vagotomy with pylosuispected recuirrent peptic ulcer disease. Eight patients roplasty has many advocates; other surgeons have reservahave symptoms relating to their ulcer surgery: one failing to tions about this procedure and suggest that it may lead to gain weight, fouir have mild dumping, and three have more difficuilties. 10,28,38,42,59 Most surgeons prefer the moderately loose stools. In addition, five patients complain Heineke-Mikulicz pyloroplasty or the Weinberg modification,24'27'30'31 while others prefer the Finney' 27'34'60 and of constipation and four of obesity. As to patient satisfaction, two patients, the one with the some the jabouilay. 15,30,52 Highly selective vagotomy without drainage has been possible recuirrence and the patient with esophageal perforation, were not pleased to have had the operation (Table used in patients without gastric outlet problems. In those patients the operative morbidity and mortality have been 4). Discussion

Suibtotal gastrectomy still has some proponents as the primary form of treatment for peptic ulcers." Under ideal circuimstances this suirgery can be performed with a low operative mortality and morbidity rate and it has a low recuirrence

rate.

The slightly higher mortality rate and the

TAIBLE .3.

Late Postoperative Problems

otis

TABLE 4. Current Status of Patients

(70 Patients) Constipation Obesity Dtumping (Mild) Diarrhea (Mild) Bleeding (Following Debauch) Probable Recurrence

low and the side effects and recurrence rates minimal."14'5'21 28,33,34,59,60 Studies have shown dumping to be present but infrequent58 and recurrence has been uncertain.60 This method deserves further study because it does not require opening into the gastrointestinal tract and has the promise of a low incidence of dumping and diarrhea.28"4 The obvihazard of vagotomy without drainage is that of delayed (70 Patients)

5 4 4 3 1 1

Died of unrelated diseases Post-prandial distress (mild) Probable recurrence (now symptomless) Patient satisfaction Average period of followup

4 7 of 66 1 of 66 64 of 66 22 months

VAGOTOMY AND DOUBLE PYLOROPLASTY

V,.l. 181 * No,. I

outlet obstruction. Some form of transection of the pylorus may be important as some investigators have suggested a relationship between peptic ulcer disease and pyloric hypertrophy. They are unsuire whether the pyloric hypertrophy preceded or was caused by the ulcer.'3'14'49 Johnston and Goligher suiggest that perhaps the selection of the type of vagotomy and pyloroplasty is less important than the skill of the suirgeon.32 The suirgical treatment for patients with gastric peptic tilcers is controversial, and most authors recommend gastric resection.63 Recently some suirgeons have found vagotomy and drainage to be unsatisfactory.5' This problem needs to be totally reviewed. We have compared the recurrence rate in the current series (1.5%) with the recurrence rate in a retrospective sttudy of 70 patients that we operated upon at an earlier time uising vagotomy and a Weinberg pyloroplasty. In the early grouip seven recurrences (10%) occurred during a similar period of observation. The improved results realized in the later series may have been due to the double pyloroplasty; other factors, however, must be considered. Diets are more realistic, practical and easier to follow, and patients are more strictly admonished to avoid alcohol, tobacco, caffeine, salicylates, steroids, and anti-cholinergic drugs. A more complete vagotomy may have been achieved by further experience. Awareness of gastrin-producing tumors has decreased the chance of overlooking this diagnosis. A last factor is most diffictult to evaluate: when an investigator takes a special interest in any field his attention to detail often leads to better results, whether or not the results are related to the new procedure or treatment. This was clearly pointed out by Dr. Francis Moore in an editorial related to new methods of burn therapy." In spite of these possibilities we feel very strongly that the method of pyloroplasty we uised greatly reduced gastric stasis and reduced the rate of ulcer recurrence. References 1. Amdrup, E. and Jensen, H. E.: Selective Vagotomy of the Parietal Cell Mass Preserving Innervation of the Undrained Antrum: A Preliminary Report of Results in Patients with Duodenal Ulcer. Gastroenterology, 59:522, 1970. 2. Breuer, R. I., Moses, H. III, Hagen, T. C. and Zuckerman, L.: Gastric Operations and Glucose Homeostasis. Gastroenterology, 62:1119, 1972. 3. Burge, H.: Vagotomy. London, Edward Arnold, 1964. 4. Burge, H., MacLean, C., Stedeford, R., et at.: Selective Vagotomy Withouit Drainage: an Interim Report. Br. Med. J., 3:690, 1969. 5. Buirge, H.: Selective Vagotomy Without Drainage. Br. Med. J., 1:172, 1971. 6. Cobb, J. S., Bank, S., Marks, I. N. and Louw, J. T.: Gastric Emptying After Vagotomy and Pyloroplasty: Relation to Some Post-operative Sequelae. Am. J. Dig. Dis., 16:207, 1971. 7. Colmer, M. R., Davis, W. T., Owen, G. M. and Shields, R.: "Dumping" After Vagotomy and Pyloroplasty. Br. J. Surg., 56:702, 1961. 8. Cotton, P. B., Rosenberg, M. T., Axon, A. T. R., et al.: Diagnostic

9.

10. 11. 12. 13. 14. 15. 16. 17.

18. 19. 20. 21. 22. 23. 24. 25. 26. 27.

28.

29. 30. 31. 32.

45

Yield of Fiberoptic Endoscopy in the Operated Stomach. Br. J. Suirg., 60:629, 1973. DeMatteis, R. A. and Hermann, R. E.: Vagotomy and Drainage for Obstruicting Duodenal Ulcers: Importance of Adequate Drainage. Am. J. Sturg., 127:237, 1974. Dignan, A. P.: A Laboratory Appraisal of the Effects of Truncal and Selective Vagotomy. Br. J. Surg., 57:249, 1970. Dragstedt, L. R. and Owens, F. M., Jr.: Supra-diaphragmatic Section of the Vaguis Nerves in Treatment of Duodenal Ulcer. Proc. Soc. Exp. Biol. Med., NY, 53:152, 1943. Dragstedt, L. R., Woodward E. R., Seito, T., et al.: The Question of Bile Reguirgitation as a Cause of Gastric Ulcer. Ann. Surg., 174:548, 1971. DtuPlessis, D. J.: Hypertrophy of the Pyloric Muscle in Gastric Ulceration. S. Afr. Med. J., 43:1076, 1969. DuiPlessis, D. J.: Primary Hypertrophic Pyloric Stenoisis in the Adult. Br. J. Stirg., 53:485, 1966. Eisenberg, M. M., Woodward, E. R., Carson, T. J. and Dragstedt, L. R.: Vagotomy and Drainage Proceduire for Duodenal Ulcer: The Resuilts of Ten Years' Experience. Ann. Surg., 170:317, 1969. Farris, J. M. and Smith, G. K.: Appraisal of the Long Term Results of Vagotomy and Pyloroplasty in 100 Patients with Bleeding Duodenal Ulcer. Ann. Stirg., 166:630, 1967. Goligher, J. C., Puilvertaft, C. N. and Watkinson, G.: Controlled Trial of Vagotomy and Gastro-enterostomy, Vagotomy and Antrectomy, and Subtotal Gastrectomy in Elective Teatment of Duodenal Ulcer; Interim Report. Br. Med. J., 1:455, 1964. Goligher, J. C., Puilvertaft, C. N., DeDombal, F. T.: Five-to-EightYear Resuilts of Leeds/York Controlled Trial of Elective Surgery for Duodenal Ulcer. Br. Med. J., 2:781, 1968. Goligher, J. C., Ptulvertaft, C. N., Irvin, T. T., et al.: Five-to-EightYear Results of Truncal Vagotomy and Pyloroplasty for Duodenal Ulcer. Br. Med. J., 1:7, 1972. Griffen, W. O., Jr., Richardson, J. D. and Bolick, R.: Gastrojejuinostomy: An Unsatisfactory Drainage Procedure for Vagotomy. Arch. Suirg., 103:140, 1971. Griffith, C. A.: Significant Fuinctions of the Hepatic and Celiac Vagi. Am. J. Suirg., 118:251, 1969. Griffith, C. A. and Harkins, H. N.: Partial Gastric Vagotomy: An Experimental Stuidy. Gastroenterology, 32:96, 1957. Harvey, R. F. and Langman, M. J. S.: The Late Results of Medical and Suirgical Treatment for Bleeding Duodenal Ulcer. Quiart. J. Med., 39:539, 1970. Hayden, W. F. and Read, R. C.: A Comparative Study of the HeinekeMikuilicz and Finney Pyloroplasty. Am. J. Surg., 116:755, 1968. Herrington, J. L., Jr.: Vagotomy-Pyloroplasty for Duodenal Ulcer: A Critical Appraisal of Early Results. Suirgery, 61:698, 1967. Hines, J. R.: A New Method of Pyloroplasty. Surg. Gynecol. Obstet., 133:100, 1971. Hoerr, S. 0. and Ward, J. T.: Late Results of Three Operations for Chronic Duodenal Ulcer: Vagotomy-Gastrojejunostomy, Vagotomy-Hemigastrectomy, Vagotomy-Pyloroplasty. Ann. Surg., 176:403, 1972. Humphrey, C. S., Johnston, D., Walker, B. E., et al.: Incidence of Dumping After Truincal and Selective Vagotomy with Pyloroplasty and Highly Selective Vagotomy Without Drainage Procedure. Br. Med. J., 3:785, 1972. Humphrey, C. S. and Wilkinson, A. R.: The Importance of Preserving the Pylortis in Suirgery for Duodenal Ulcer. Br. J. Surg., 59:779, 1972. Jordan, P. H.: Elective Operations for Duodenal Ulcer. N. Engl. J. Med., 287:1329, 1972. Jordan, P. H., Jr. and Condon, R. E.: A Prospective Evaluation of Vagotomy-Pyloroplasty and Vagotomy-Antrectomy for Treatment of Duiodenal Ulcer. Ann. Surg., 172:547, 1970. Johnston, D. and Goligher, J. C.: The Influence of the Individual

46 33.

34. 35. 36.

37. 38. 39. 40.

41.

42. 43.

44.

45. 46.

47. 48.

49.

HINES AND OTHERS Stirgeon and of the Type of Vagotomy upon the Insulin Test After Vagotomy. Guit, 12:963, 1971. Johnston, D., Htumphrey, C. S., Walker, B. E., et al.: Vagotomy Withouit Diarrhea. Br. Med. J., 3:788, 1972. Johnston, D. and Wilkinson, A. R.: Highly Selective Vagotomy Withouit a Drainage Proceduire in the Treatment of Duodenal Ulcer. Br. J. Suirg., 57:289, 1970. Kennedy, T. and Connell, A. M.: A Douible-blind Controlled Trial of the Value of Selective and Total Vagotomy in the Surgical Treatment of Duiodenal Ulcer. Br. J. Suirg., 56:385, 1969. Kennedy, T. and Connell, A. M.: Selective or Truncal Vagotomy? A Douible-blind Randomized Controlled Trial. Lancet, 1:899, 1969. Korman, M. G., Hansky, J., Couipland, G. A. E. and Cuimberland, V. H.: Seruim Gastrin in Duiodenal Ulcer. Guit, 13:163, 1972. Kraft, R. O., Fry, W. J., Wilhelm, K. G. and Ransom, H. K.: Selective Gastric Vagotomy: A Critical Reappraisal. Arch. Surg., 95:625, 1967. Lynch, J. D., Jernigan, S. K., Trotta, P. H. and Clemes, B. E.: Incidence and Analysis of Failuire with Vagotomy and HeinekeMikuilicz Pyloroplasty. Suirgery, 58:482, 1965. Marckmann, A., Baden, H. and Amdrup, E.: Selective Vagotomy Combined with Drainage Proceduire in Treatment of Duodenal Ulcer: Selective Anterior and Total Posterior Vagotomy Compared with Bilateral Selective Vagotomy in One Huindred Sixteen Patients. Acta. Chi. Scand. (Suppl.), 396:41, 1969. Mason, M. C. and Clark, C. G.: Suirgery for Dtuodenal Ulcer. Br. J. Sturg., 56:815, 1969. Mason, M. C., Giles, G. R., Graham, N. G., et al.: An Early Assessment of Selective and Total Vagotomy. Br. J. Suirg., 55:677, 1968. Miller, D. F., Mason, J. R., McArthtir, J. and Gordon, I.: A Randomized Prospective Trial Comparing Three Established Methods of Gastric Decompression After Vagotomy. Br. J. Suirg., 59:605, 1972. Moore, F.: (Editorial) Reflections on New Treatments for Buirns-Caveat Legor., JAMA, 225:294, 1973. McKelvey, S. T. D.: Gastric Incontinence and Post-Vagotomy Diarrhea. Br. J. Sturg., 57:741, 1970. Ochsner, A., Zehnder, P. R. and Trammell, S. W.: The Surgical Treatment of Peptic Ulcer: A Critical Analysis of Resuilts From Subtotal Gastrectomy and From Vagotomy Pluis Partial Gastrectomy. Suirgery, 67:1017, 1970. Postlethwait, R. W.: Five Year Follow-uip Resuilts of Operations for Dtuodenal Ulcer. Suirg. Gynecol Obstet., 137:387, 1973. Price, W. E., Grizzle, J. E., Postlethwait, R. W., et al.: Results of Operation for Duodenal Ulcer. Suirg. Gynecol Obstet., 131:233, 1970. Raffensperger, E. C.: Time Requiired for the Development of Pyloric Muiscle Hypertrophy in an Aduilt. Gastroenterology, 28:458, 1955.

Aiiii. Stitrg. * Jantiary 1975

50. Robbs, J. V., Bank, S., Marks, I. N. and Louiw, J. H.: Selection of Operation for Duiodenal Ulcer Based on Acid Secretory Sttudies: A Reappraisal. Br. J. Suirg., 60:601, 1973. 51. Savage, L. E. and McVay, C. B.: Suirgical Management of Peptic Ulcer. Am. J. Sturg., 119:191, 1970. 52. Sawyers, J. L. and Scott, H. W. Jr.: Selective Gastric Vagotomy with Antrectomy or Pyloroplasty. Ann. Suirg., 174:541, 1971. 53. Sawyers, J. L., Scott, H. W. Jr., Edwards, W. H., et al.: Comparative Stuidies of the Clinical Effects of Trtncal and Selective Gastric Vagotomy. Am. J. Stirg., 115:165, 1968. 54. Small, W. T. and Jahadi, M. R.: Pyloroplasty and Vagotomy for Duiodenal Ulcer: A Fouir-to-Eleven-Year Follow-uip Stuidy. Am J. Suirg., 119:372, 1970. 55. Smith, G. K. and Farris, J. M.: Reappraisal of the Long Term Effects of Selective Vagotomy. Am. J. Suirg., 117:222, 1969. 56. Stempien, S. J., Dagradi, A. E., Lee, E. R. and Simonton, J. H.: Statuis of Duiodenal Ulcer Patients Ten Years or More After VagotomyPyloroplasty (V.P.). Gastroenterology, 58:997, 1970. 57. Stempien, S. J., Dagradi, A. E., Lee, E. R. and Simonton, J. H.: Stattus of Duiodenal Ulcer Patients Ten Years or More After VagotomyPyloroplasty (V.P.). A.M. J. Gastroenterol., 56:99, Auig., 1971. 58. Tompkin, A.M.B.: Selective Vagotomy. Br. J. Suirg., 56:845, 1969. 59. Tovey, F. I.: Selective Vagotomy Without Drainage. Br. Med. J., 4:236, 1969. 60. Wastell, C., Colin, J. F., MacNatighton, J. I. and Gleeson, J.: Selective Proximal Vagotomy With and Without Pyloroplasty. Br. Med. J., 1:28, 1972. 61. Weinberg, J. A.: Vagotomy With Pyloroplasty in the Treatment of Dtuodenal Ulcer-Sturgical Aspects. Am. J. Gastroenterol., 21:296, 1954. 62. Welch, C. E.: Suibtotal Gastrectomy for Dtuodenal Ulcer. Suirg. Clin. North. Am., 46:339, 1966. 63. Welch, C. E. and Buirke, J. F.: Gastric Ulcer Reappraisal. Surgery, 65:708, 1969. 64. Wheldon, E. J., Venables, C. W. and Johnston, I. D. A.: Late Metabolic Sequielae of Vagotomy and Gastroenterostomy. Lancet, 1:437, 1970. 65. Whittaker, L. D., Jr., Juidd, E. S. and Statuffer, M. H.: Analysis of Use of Vagotomy with Drainage Procedure in Suirgical Management of Duiodenal Ulcer. Surg. Gynecol. Obstet., 125:1018, 1967. 66. Wilbuir, B. G. and Kelly, K. A.: Effect of Proximal Gastric, Complete Gastric, and Truincal Vagotomy on Canine Gastric Electric Activity, Motility, and Emptying. Ann. Surg., 178:295, 1973. 67. Wilkinson, A. R. and Johnston, D.: Effect of Truincal, Selective and Highly Selective Vagotomy on Gastric Emptying and Intestinal Transit of a Food-Bariuim Meal in Man. Ann. Suirg., 178:190, 1973. 68. Wray, R. C., Jr. and Wangensteen, S. L.: Resuilts of Vagotomy and Pyloroplasty for Peptic Ulcer. Suirgery, 66:502, 1969.