SUMMARYThe 5-year results of a double-blind, randomized, controlled trial of selective versus truncal vagotomy, each with pyloroplasty, are reported. Of IOO patients entering the trial, 95 are available for study. There were 4 suspected or proven recurrent ulcers in the truncal group and I suspected but no proven recurrence in the selective group. The incidence of episodic diarrhoea was significantly less in the selective group; 4 mild and no severe cases compared with 11 mild and t severe cases among the truncal vagotomies. There was no severe dumping; mild symptoms were more common in the selective group but not significantly so. Miscellaneous dyspeptic symptoms were a little more common in the truncal group. Taking all these symptoms into consideration, the Visick clinical status of the selective group was superior. Weight changes, haemoglobin levels, and calcium levels were similar and satisfactory in each group. Selective vagotomy is superior to truncal vagotomy when each is combined with pyloroplasty.
In a prospective three centre study oesophageal transection and gastric devascularisation have been compared with endoscopic sclerotherapy in the long term management of bleeding oesophageal varices. Cirrhotic patients (Child's A or B grade) with documented bleeding oesophageal varices were treated initially with emergency sclerotherapy, and after five days stability, were allocated to one of the two treatment regimes. The endoscopic sclerotherapy group underwent regular sclerotherapy until variceal obliteration while those undergoing surgery were not endoscoped unless bleeding recurred, when they were treated by sclerotherapy if appropriate. Ninety two patients were eligible for analysis (68% alcoholic cirrhosis; mean age 50.1 years) and follow up was achieved for a mean of 52*5 months (range The theoretical advantage of this technique is that it deals directly with the oesophageal varices without affecting liver perfusion: a prospective study has shown it to be superior to standard and distal splenorenal shunts in patients with portal hypertension secondary to schistosomiasis.1We report here the results of a three centre prospective randomised controlled trial comparing repeated endoscopic injection sclerotherapy with the modified transection and devascularisation procedure in the long term management of patients with cirrhosis and oesophageal variceal haemorrhage. In addition to morbidity and mortality, we have examined and compared the economic costs of the two management strategies. Methods TRIAL DESIGNThe major objective of the trial was concerned with the long term management of patients after their initial variceal bleeds. In order to minimise the influence of complications from the initial bleed, patients were only considered to be eligible for entry into the trial once they were stable with no evidence of any bleeding for five days and also no evidence ofany other destabilising medical conditions (such as septicaemia and renal failure).All patients admitted with their first variceal haemorrhage were resuscitated and treated by urgent endoscopic sclerotherapy. After a minimum period of five days stability they were eligible for randomisation and inclusion into the trial. Those who rebled within the first five days were then treated by further sclerotherapy and were randomised if and when they were free of bleeding for this period of time. Specific entry 1553 on 7 May 2018 by guest. Protected by copyright.
A double‐blind, randomized, controlled trial of Finney pyloroplasty and gastrojejunostomy, each with selective vagotomy, is reported. There were no operative deaths but 5 patients have subsequently died or have been lost to follow‐up, leaving 94 patients, with a mean follow‐up time of 3 1/2 years. There has been 1 proven recurrence after gastrojejunostomy and 2 after pyloroplasty, with 1 further suspected recurrence in each group. The clinical grading marginally favoured gastrojejunostomy. There was no significant difference in the incidence of bilious vomiting, dumping, diarrhoea, or other disturbances, but there was a significantly greater increase in bowel frequency after pyloroplasty. Weight changes were similar, and there was no gross anaemia or calcium deficiency in either group. Gastrojejunostomy is reversible and pyloroplasty is not, and therefore we recommend gastrojejunostomy as the drainage procedure of choice when drainage is necessary after vagotomy.
From August 1969 to December 1989, 600 patients had elective proximal gastric vagotomy for duodenal ulceration with an operative mortality of 0.2 per cent. Of these, 372 patients had surgery over 10 years ago. Three hundred and forty-two patients survived for more than 10 years and, in a prospective study, 305 were reviewed, forming the basis of this 10-20-year follow-up report. Forty-six (15 per cent) have had recurrent ulceration; 80 per cent of these developed symptoms within 5 years and no patient has had recurrence after 13 years. Although 29 patients required reoperation for recurrent ulceration, the current patient satisfaction rate for Visick grades I and II is 92 per cent. Only two patients required reoperation because of gastric stasis. It is concluded that proximal gastric vagotomy is a safe and satisfactory first choice operation for duodenal ulceration.
SUMMARYA series of 117 consecutive patients having operations for recurrent peptic ulcer is reported. There were no initial deaths but 9 patients developed further recurrent ulcer and 2 of 8 who had a third operation died, giving an overall patient mortality of 1.7 per cent. A further 6 patients underwent a third operation to correct bile vomiting or dumping, with no deaths.The mean time of onset of symptoms of recurrent ulcer was 1.9 years after proximal gastric vagotomy, 3.2 years after vagotomy and drainage, 3.3 years after gastrectomy and 1 2 6 years after gastrojejunostomy.One hundred and four patients were followed for more than I year (mean 5.2 years) and the result was good in 77 per cent. After a third operation the proportion of good results was improved to 88 per cent.Second recurrence occurred in I of 43 patients after revagotomy and gastrectomy, in 2 of 28 after resection alone and in 6 of 33 after vagotomy or revagotomy alone (P<0.05). When the patients whose primary operation included neither vagotomy nor gastric resection were excluded, there was a similar trend but the diferences were not significant. It is suggested that gastric resection or re-resection should be combined with vagotomy or revagotomy whether the primary operation has been gastrectomy, vagotomy with or without drainage or gastrojejunostomy alone.
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