Intraoperative Assessment of the Proximal Gastric Vagotomy Completeness by a Simple pH Test

Abstract

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).

One Thousand One Hundred and Fifty Proximal Gastric Vagotomies for Duodenal and Related Gastric Ulcer

“…Finally, fullness was important in the first experimental vagoto mies; 3 of the 10 initial cases were more gastric than proximal gastric vagotomies and required antrectomy Table III shows the Visick staging of the 931 cases followed up and, separately, of the 306 cases followed up for more than 10 years. There is a good correlation (r = 0.93-0.98) between these Visick grades and the acid secretory values [10]. Table IV shows the pre-and post operative acid secretory values in DU and GU types II and III.…”

“…On correlating pH of the intraoperative experiences with the postoperative secretory evaluation and with the number of DU recurrences, or persistences, the r-index was found to be 0.98 [10]. We have only one DU recur rence among the 489 PGVs with all five points of pH direct mucosa test over 6.4 ( fig.…”

“…The pH meter intraoperative test [8,10] forwards knowledge of the completeness of secretory vagotomy during the surgical act itself (0.2% recurrences in 489 PGVs with all five intraoperative points pH-tested at over 6.4), and also prevents exceeding denervations 'just in case'. Such overdenervations were evident among our initial mistakes with our first 50 PGVs.…”

“…The situation is different with the new GU, com monly associated with gastric retention (as happened in some of the first Dragsted thoracic vagotomies, without drainage), [5,6,10] and with a greater interval between surgery and manifestation, i.e., 23 months against the 10 months for DU recurrence or persistences. Acid secre- tion output in turn falls within very normal limits ( fig.…”

Complete Proximal Gastric Vagotomy following Gastroepiploic Nerve Section

“…In September 1973, we were able to determine pH directly on the stimulated secretory mucosa using a transesophageal electrode (GR 282 C); this improved precision and efficacy in locating the areas still innervated [1]. Finally, in October 1976. monitored experiments [5] made it possible to establish a value of 6.5 as the minimum pH defining complete denervation of an area of gastric mucosa. The results obtained on following these criteria were very good (ta ble 1): of 519 PGVs presenting a pH over 6.4 at five monitoring points [5], only two relapses occurred (85% follow-up) (6).…”