Clinical Results of Parietal Cell Vagotomy (Highly Selective Vagotomy) Two to Four Years After Operation

Abstract

In Leeds and Copenhagen 271 patients were treated electively for duodenal ulcer by parietal cell vagotomy without drainage between 1969 and 1972 inclusive, with no operative deaths. 108 patients have been followed up 2-4 years since operation. Gastric stasis necessitating re-operation occurred in only 2 cases. Gastric ulcer developed in 2 cases, and in 3 cases recurrence of the duodenal ulcer was suspected but was unconfirmed at re-operation. Uncontrolled comparison with the results of partial gastrectomy and of vagotomy with drainage, as performed at these two centers, has shown that after parietal cell vagotomy without drainage there is a much lower incidence of dumping, diarrhea and bile vomiting, and, on overall assessment, a greater proportion of perfect or very good results.

Physiological and Clinical Significance of Highly Selective Vagotomy without a Drainage Procedure

“…As mentioned earlier, early dumping, diarrhoea and bilious vomiting are much less common after HSV than after TV or SV with a drain age procedure [3,32,42]. Gastric stasis is no more common.…”

“…Holle and H art [30] were the first to preserve the vagal nerve supply to the antrum, without resection, in man, but they insist on the need for a concomitant pyloroplasty (or antrectomy on occasion), whereas we think that the damage to the terminal antrum and to the pylorus which is produced by a pyloroplasty is unnecessary. Since HSV and PCV are so closely similar, and since to date they have yielded virtually identical results [3,30], they will be considered together under the title of HSV.…”

“…Food residues have been found in the stomach after an overnight fast in less than 1% of all the secre tory tests which were performed more than 2 months after HSV in Leeds and Copenhagen. If patients with clinical evidence of pyloric stenosis are ex cluded, fewer than 1% of patients who underwent HSV for duodenal ulcer have required re-operation for the relief of gastric stasis [3]. At the Gastric Follow-up Clinic, symptoms suggestive of gastric retention, such as vomiting and flatulence, have been less common after HSV than after TV or SV with a drainage procedure.…”

“…Although HSV does not produce gastric retention, the pattern of gastric emptying of fluids is altered. There is an initial phase of rapid emptying, which is followed by a more normal pattern of emptying [9,56,62,76], The rapid initial phase of gastric emptying after HSV is associated with clinical symptoms of mild early dumping in about 6% of patients [3], but the abnormality of the emptying pattern is much less marked than that which is produced by TV or SV with a drainage procedure. Both dumping [31] and diarrhoea [42] have been shown to be significantly less common after HSV than after TV + P or SV + P. After HSV in dogs, the rate of gastric emptying of solids is normal, whereas after TV or SV without a drainage procedure, gastric emptying of solids is significantly prolonged [76], The more rapid rate of gastric emptying of liquids after vagotomy is due to increased intragastric pressure, secondary to impairment of 'receptive relaxation' by the vagotomized smooth muscle of the stomach [36,76], The presence of a pyloroplasty has been shown to exaggerate the abnormality of emptying which is produced by vagotomy [9], Thus, gastric emptying is not normal after HSV, and 'dumping' can still occur, but the pattern of gas tric emptying is much closer to the normal than is the pattern after TV or SV with a drainage procedure.…”

“…Both dumping [31] and diarrhoea [42] have been shown to be significantly less common after HSV than after TV + P or SV + P. After HSV in dogs, the rate of gastric emptying of solids is normal, whereas after TV or SV without a drainage procedure, gastric emptying of solids is significantly prolonged [76], The more rapid rate of gastric emptying of liquids after vagotomy is due to increased intragastric pressure, secondary to impairment of 'receptive relaxation' by the vagotomized smooth muscle of the stomach [36,76], The presence of a pyloroplasty has been shown to exaggerate the abnormality of emptying which is produced by vagotomy [9], Thus, gastric emptying is not normal after HSV, and 'dumping' can still occur, but the pattern of gas tric emptying is much closer to the normal than is the pattern after TV or SV with a drainage procedure. Clinically, HSV halves the incidence of early dumping and virtually eliminates so-called 'post-vagotomy' diarrhoea [3,31,42], Bilious vomiting is also much reduced [3].…”