Proximal gastric vagotomy (PGV) may be the best surgical treatment for duodenal ulcer (DU) if their recurrences, due mostly to insufficient denervation, can be reduced. This review demonstrates that direct gastric mucosal pH measurement, when accurately done while performing the surgery (617 cases tested among 928 PGVs), increases the number of successfully completed secretory vagotomies, thereby reducing recurrent DU rates. Comparison with postoperative secretory tests shows that testing for pH levels > 6.4 can be useful to help all surgeons make timely corrections and achieve a complete vagotomy. Aiming for a pH > 6.4, we had only one recurrence among 369 cases (79% follow-up; 5.4 years median trial time).
This paper covers 1,150 proximal gastric vagotomies (PGV) performed from August 1970 to February 1986 on 1,017 duodenal ulcers (DU) and 133 gastric ulcers (GU) types II and III (178 emergency cases). Our technique is described: no isolation of vagal trunk and branches, double and simultaneous ligature and section of the epiploon sheets and control of vagal denervation completeness with pH direct mucosa test. Mortality is 0.1 % in 972 elective PGVs (2 nonrelated deaths among 178 emergency cases) and morbidity is minimal and temporary. Follow-up covers 81 % (mean, 84 months) and involves an interview, X-ray examination, endoscopic control and acid secretory output valoration (69%). Visick stages: 82, 10, 5 and 4% (in cases operated on more than 10 years ago, the Visick stages are: 69, 22, 3 and 6%). Recurrences: 19 DUs (94% inadequate vagotomies) and 15 ‘new GU’ (adequate secretory denervation and 3 of 4 are pyloric stenoses only dilatated). We have only 1 DU recurrence in 489 PGVs with pH over 6.4 at all five gastric mucosa points.
We describe a simple surgical access to the lower mediastinum, using a suprahepatic laparotomic approach through the diaphragm in its interpericardic-hiatal segment. This transverse phrenotomy is particularly useful when the subhepatic-hiatal area is obstructed by adherences from earlier operations in the area; such adherences are almost absent at suprahepatic level. Care must be taken to avoid damaging the pericardial sac. A ribbon is passed around the easily identified esophagus (intubated by a Levin sonde), which facilitates sectioning of the vagal trunk; in the case of a thoracic vagotomy, this represents the main indication of the approach. The procedure would also be of use in repairing the upper pole in tedious reoperative dissections due to antirefiux failure (in particular, following post-Nissen sliding), and in cardia cancer affecting the hiatal ring. Eleven troncular revagotomies, four carcinomas of the cardias and two reinterventions following relapses in antirefiux procedures point to minimal trauma through transphrenic access, with a risk well below that of a thoracotomy or laparophrenothoracotomy, and all without sacrificing efficiency.
The authors present 611 and 262 case histories of patients with breast cancer, studied 5 and 10 years after mastectomy, respectively; 27 clinical and 10 histologic parameters were considered for the statistical evaluation, in order to define an Individualized Prognostic Index (IPI) for breast cancer survivability. The probability of survival was estimated by a Bayesian formula using selected prognostic parameters, these parameters were placed in order of discriminant resolution and, for the calculation of the IPI, were selected according to their importance, as it follows: 5 years after surgery: percent affected nodules, dermal infiltration, TNM phase, Scarff‐Bloom index and evolutive outbreak (PEV); 10 years after surgery: TNM phase, dermal infiltration, percent affected nodules and Scarff‐Bloom index. The current information considers that out of several parameters, the selected prognostic parameters used for the IPI are sufficient to establish probability tests and a reliable estimation of life expectancy following breast cancer surgery.
Proximal gastric vagotomy (PGV) is the operation of choice in duodenal ulcer (DU), in view of its minimal morbidity-mortality. We discuss the number of recurrences (R) involved in this technique; most are the result of insufficient denervation, whereas a few ‘new gastric ulcers’ are due to emptying problems. Only 1 year after our first PGV (1970), we attempted the incorporation of postoperative tests (pH of gastric juice samples) peroperatively. Later it became possible to situate the electrode on the gastric mucosa after passing it down the esophagus. Finally, the electrode was pressed against the mucosa, and a minimum pH of 6.4 was found to define complete denervation. By this criterion, only two Rs (0.4%) were observed in 519 PGVs. An area resisting pH rise was established: in one fifth of cases the preantral region only rises to pH 7 after gastroepiploic nerve sectioning. We carried out a prospective randomized study of PGV + sectioning of the gastroepiploic nerve (Sge), PGV + pH test and PGV alone. The study involved 293 cases (1980), including 269 followed up for an average of 57 months; Rs were observed in 1.4, 1.7 and 10.1% of cases with the first, second and third method, respectively. In our opinion, PGV + Sge with cardiohiatofundolysis may reduce R to under 4 %.
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