Selective Vagotomy without Drainage. An Interim Report

Abstract

Rundles (1945), who, in discussing the oesophageal changes, considered that the whole problem was a challenge. Mandelstam and Leiber (1967) concluded that the oesophageal motor dysfunction was a common finding in diabetic neuropathy-gastroenteropathy, and that on occasion it results in dysphagia. In their group 12 had oesophageal dysfunction but only three had symptoms, while their control group had no changes at all.The present study indicated that abnormal oesophageal function was not limited to one group and therefore that the abnormality is not specific or exclusive to the diabetic neuropathy group. The chief finding was an incoordination of the primary peristalsis in the body of the oesophagus. In each group there were cases of sliding hiatal herniae associated with both normal and abnormal sphincteric action and peristalsis. With the exception of the non-diabetic symptomatic group, however, there was no correlation between the clinical picture and the cineradiographic motility studies. Similar findings of oesophageal dysfunction were reported in alcoholic neuropathy and normals (Winship et al., 1968).Furthermore, there is no explanation of the pathogenesis which could account for these changes occurring in all the groups at all ages. Vagal degeneration and myopathy of the oesophageal muscle have been incriminated, but with no absolute proof. Recently it has been considered that diabetic neuropathy is a metabolic defect predominantly affecting fat metabolism within the cell which is associated with hyperplasia of the basement membrane (Bischoff, 1968). This latter investigation was carried out on peripheral nerves, and not on the oesophagus or on the rest of the gastrointestinal tract.The conclusion therefore drawn from the present study is that identical cineradiographic and manometric evidence of oesophageal dysfunction can occur in all four groups investigated and not only in those affected by diabetes, with or without neuropathy. British Medical Yournal, 1967, 4, 311. Mandelstam, P., and Leiber, A. (1967 Journal, 1969, 3, 690-693 Summary: The results of surgical treatment for duodenal ulcer were compared in two groups of patients -51 who had undergone selective vagotomy without drainage and 17 who had had selective vagotomy and pyloroplasty. It is suggested that in the absence of organic pyloric or duodenal stenosis the former method seems both preferable and desirable, since postoperatively dumping does not occur and there is a steady improvement in gastric emptying.

Highly selective vagotomy without a drainage procedure in the treatment of duodenal ulcer

“…In man, preservation of an innervated antrum in the acid stream was pioneered successfully by Ferguson, Billings, Swensen, and Hoover (1960 Holle, 1967) in which the antrum has been left innervated in several hundred patients; but it appears that a concomitant drainage procedure or resection is invariably added. Bilateral selective vagotomy without a drainage procedure has been used by Burge, MacLean, Stedeford, Pinn, and Hollanders (1969) in treating more than IOO selected cases of duodenal ulceration. Studies of gastric emptying (Shiina and Griffith, 1969) and motility (Wohlrabe and Kelly, 1959; Stavney, Kato, Griffith, Nyhus, and Harkins, 1963) in dogs subjected to bilateral selective vagotomy without drainage suggest, however, that antral motility is much reduced and that gastric stasis is severe in some cases.…”

The effect of preserving antral innervation and of a pyloroplasty on gastric emptying after vagotomy in man

“…Proximal gastric vagotomy denervates the acidsecreting area of the stomach but preserves the innervation to the gastric antrum. Burge, MacLean, Stedeford, Pinn, and Hollanders (1969) suggested that a drainage procedure was not necessary with selective vagotomy in the absence of duodenal stenosis.…”

Gastric Stasis and Gastric Ulcer after Selective Vagotomy Without a Drainage Procedure

“…It soon became clear that there were many complications resulting from gastric retention (Jackson, 1948;Slaney et al, 1956), and Dragstedt et al (1947) were quick to point out that most patients with duodenal ulcer required some form of drainage operation in addition to vagotomy. Burge et al (1969) suggested that selective vagotomy would retain sufficient innervation to the prepyloric and pyloric regions of the stomach via the pyloric branch of the anterior vagus and so allow normal gastric emptying to occur. Nevertheless, Franksson (1948) had earlier attempted to use bilateral selective vagotomy without drainage, but because of the complications of gastric retention, even in patients with no ulcer stenosis, he later abandoned the operation (Shiina and Griffiths, 1969).…”

“…The operative technique used for selective vagotomy was similar to the technique described by Burge et al (1969), with careful preservation of both the coeliac and the hepatic branches of the vagus nerves. Ten patients were from Birmingham and five from Liverpool: all were men aged 21 to 63 years.…”

“…In an interim report by Burge et al (1969) it was suggested that if patients with duodenal ulcer without stenosis are treated by selective vagotomy, a drainage operation such as pyloroplasty or gastrojejunostomy may be omitted. In their experience there were no serious or permanent problems resulting from delayed gastric emptying in these patients.…”