Increased mortality in prostate carcinoma and smoking-related disease after parietal cell vagotomy: a long-term follow-up study.

OBJECTIVE: There is an increased risk of gastrointestinal carcinoma and smoking-related diseases after partial gastrectomy for peptic ulcer disease. The purpose of this study was to evaluate long-term cancer incidence and mortality after parietal cell vagotomy (PCV), a surgical method with a low rate of side effects, but creating hypochlorhydria in the stomach mimicking long-term treatment with antisecretory drugs. MATERIAL AND METHODS: Data on 383 ulcer patients operated on with PCV during 1971-80 at Lund University Hospital were compared with the national registers for cause of death and cancer incidence for selected diagnoses. Median follow-up was 28 years and 31 years, respectively. Standardized mortality ratios (SMRs) and standardized incidence ratios (SIRs) were calculated. RESULTS: An increased incidence of cancer in the respiratory organs (SIR 1.97, 95% CI: 1.08-3.31) and prostate carcinoma (SIR 1.85, 95% CI: 1.22-2.69) was found, and among men also an increased mortality in prostate carcinoma (SMR 3.85, 95% CI: 1.41-8.38) and chronic respiratory disease (SMR 2.76, 95% CI: 1.01-6.02). Overall mortality was similar to that of the background population and no increased risk of gastrointestinal malignancies was observed. CONCLUSIONS: Patients with peptic ulcer operated on with PCV have a long-term increased risk of smoking-related diseases, but PCV does not seem to increase the risk of gastrointestinal carcinoma. An increased risk of, and mortality in prostate carcinoma was found, a cancer previously not found to be related to smoking. This might be the result of surgery-induced hypochlorhydria, which warrants further investigation in patients on long-term proton-pump inhibitors.

[The newly occurred and recurrent gastric ulcers after organ-preserving operations for the ulcer disease].

The literature data and the results of own investigations on gastric recurrent ulcers occurrence after organpreserving operations performance for the ulcer disease are summarized. The data on gastric recurrent ulcers occurrence rate are adduced. Modern views on possible causes of occurrence, necessary volume and informativity of investigation methods and tactics of treatment are presented. Gastroduodenal motor-evacuation function disorders, duodenogastric reflux and gastric hypersecretion are suggested as a most frequent causes of gastric recurrent ulcers occurrence. The method of operative intervention choice for recurrent gastric ulcer is determined by the cause of its occurrence, as well as the character of ulcer complication and the kind of previous surgical procedure performed.

Effect of vagotomy during Roux-en-Y gastric bypass surgery on weight loss outcomes.

BACKGROUND: During Roux-en-Y gastric bypasses (RYGB), some surgeons elect to perform a vagotomy to reduce symptoms of gastro-oesophageal reflux (GER). Routine vagotomy during RYGB may independently affect weight loss and metabolic outcomes following bariatric surgery. We aimed to determine whether vagotomy augments percent excess weight loss in obese patients after RYGB. METHODS: We examined the effect of vagotomy in 1278 patients undergoing RYGB at our institution from 2003 to 2009. Weight and percent excess weight loss (%EWL) were modelled at three months and annually up to five years using a longitudinal linear mixed model controlling for differences in age, gender, initial body mass index (BMI), ideal body weight, and presence of vagotomy. RESULTS: Vagotomy was performed on 40.3% of our cohort. Vagotomy patients had significantly lower initial BMI (46.4±6.2 vs. 48.3±7.7kg/m(2), p<0.001), but there were no other significant differences at baseline. The strongest predictor of %EWL over time was initial BMI, with lower BMI patients exhibiting greater %EWL (p<0.001). Age and gender effects were also significant, with younger patients (p<0.04) and males (p<0.002) attaining greater %EWL. Vagotomy had no effect on %EWL in either simple or multiple regression models. CONCLUSION: Our series suggest that vagotomy does not augment %EWL when performed with RYGB.

Proximal gastric vagotomy with drainage for obstructing duodenal ulcer.

The optimal treatment for obstructing duodenal ulcer is controversial because of questions about the efficacy of proximal gastric vagotomy (PGV) in controlling the primary ulcer diathesis. Impressed with the theoretic advantages of PGV with drainage as a primary treatment for this problem, we have treated 37 suitable patients by this approach. All patients underwent endoscopic examination and barium meal study that proved the diagnosis. PGV, including division of the gastroepiploic nerves as indicated by intraoperative testing, was followed by Jaboulay gastroduodenostomy (18), Finney pyloroplasty (12), Heineke-Mikulicz pyloroplasty (3), anterior hemipylorectomy (2), duodenoplasty (1), and gastroenterostomy (1). No recurrent ulcers were seen during a mean follow-up of 4.6 years. Three patients had mild early dumping at infrequent intervals. Bilious vomiting, alkaline gastritis, and other postgastrectomy complaints were recorded infrequently. PGV with drainage is a good treatment for the obstructing ulcer and does not have as many morbid risks as alternative operative procedures.

Proximal gastric vagotomy versus selective vagotomy with antrectomy: results of a prospective, randomized clinical trial after four to twelve years.

This prospective, randomized study of selective vagotomy with antrectomy (SVA) versus proximal gastric vagotomy (PGV) for patients with duodenal ulcer compares the incidence of recurrent duodenal ulcer and postoperative morbidity during a 4- to 12-year follow-up period. In 46 patients with SVA there were no recurrent ulcers, but 26% of these individuals had serious digestive problems that were not amenable to medical treatment. The 40 patients with PGV had eight recurrent ulcers (20%), but five of these were found in the first 15 patients (33%) compared with three in the 25 patients (12%) who had operations after the need for extensive periesophageal denervation was discovered in the mid-1970s. Most recurrent ulcers were amenable to medical treatment, but 5% of the patients who had PGV had postoperative dysphagia that required periodic bougienage. The data are consistent with several interpretations, depending on the bias of the individual. However, based upon the fact that recurrent ulcers could be managed nonoperatively after PGV versus the lack of effective treatments for postgastrectomy complaints after SVA, it is reasonable to consider wider use of PGV. There are reasons to believe that the variable ulcer recurrence rates after PGV can be explained by subtle differences in operative technique, including those based upon use of the Congo red test for completeness of vagotomy. Unlike SVA, PGV remains an operative procedure in evolution that requires further clinical investigation. At this time either operation can be applied if both the surgeon and the patient have a clear understanding of the possible effects.

Prospective, randomized trial of selective proximal vagotomy with ulcer excision and partial gastrectomy with gastroduodenostomy in the treatment of corporeal gastric ulcer.

In a prospective, randomized trial, selective proximal vagotomy with complete ulcer excision was compared with partial gastrectomy with gastroduodenostomy for the treatment of primary corporeal gastric ulcer in 30 patients. The results were evaluated by clinical follow-up examinations at regular intervals, endoscopy, and blood tests. The mean follow-up period was 3 years for both operations. There was no mortality. Postoperative complications, ulcer recurrence rates, the overall clinical results (Visick classification), and blood test results were similar in the two groups. Three of 15 selective proximal vagotomy patients were classified grade IV due to recurrent ulcer (two patients) or dumping (1 patient), and 2 of 14 partial gastrectomy patients as were classified grades III (epigastric pain) and IV (recurrent ulcer). Considering the risk for late symptoms of impaired resorption and gastric cancer after partial gastrectomy, the similar results with selective proximal vagotomy and partial gastrectomy justify further trials of selective proximal vagotomy with ulcer excision for treatment of corporeal gastric ulcer.

Proximal gastric vagotomy interferes with a fundic inhibitory mechanism. A hypothesis for the high recurrence rate of peptic ulceration.

The mucosa of the proximal stomach contains a powerful inhibitor of acid secretion and gastrin release. The release of this inhibitor is dependent on intact vagal innervation of the proximal stomach. Thus, proximal gastric vagotomy interferes with the release of the inhibitor. After proximal gastric vagotomy for peptic ulcer, recurrence rates increase over time. In addition, there is some recovery of acid secretion. Although nerve regeneration or sprouting has been suggested as the possible explanation for these events, we propose that interference with the inhibitory mechanism of the proximal stomach may be another possible explanation for the increasing ulcer recurrence rates after proximal gastric vagotomy. At present, this is only a hypothesis and is suggested only by indirect evidence. Direct testing of the hypothesis will require complete purification of the inhibitor and the development of a specific radioimmunoassay.

Ten-year follow-up of a prospective, randomized trial of selective proximal vagotomy with ulcer excision and partial gastrectomy with gastroduodenostomy for treating corporeal gastric ulcer.

Between 1975 and 1980, 30 patients with type I corporeal gastric ulcer were randomly allocated to undergo selective proximal vagotomy with ulcer excision or partial gastrectomy with gastroduodenostomy. Sixteen patients underwent selective proximal vagotomy (1 was excluded from the follow-up since microscopic examination of the excised ulcer revealed an early gastric cancer) and 14 underwent partial gastrectomy. No significant differences in the clinical results were found 3 years after surgery. During a median follow-up of 10 years, ulcer recurred in 3 patients after selective proximal vagotomy and in 2 after partial gastrectomy. One patient in each group had recurrent ulcer without symptoms and received no treatment. Two selective proximal vagotomy patients and three partial gastrectomy patients had epigastric pain with or without ulcer. One patient with selective proximal vagotomy underwent a second operation because of epigastric pain and recurrent ulcer. Bowel habits remained unchanged in all but one patient in each group, and mild or moderate dumping was recorded for two patients in each group. Very good or good results (modified Visick scale) were recorded for 11 of 15 patients after selective proximal vagotomy and for 10 of 14 patients after partial gastrectomy. Except for one patient in each group who had moderate dumping, patients classified as Visick III or IV had no symptoms during treatment with antacids or H2-blockers, or had asymptomatic ulcers and needed no treatment. Selective proximal vagotomy reduced the median acid response to insulin hypoglycemia and to pentagastrin by 100% and 80%, respectively, for at least 3 to 5 years, and partial gastrectomy reduced the median acid response to pentagastrin by 97%. In our opinion, selective proximal vagotomy with ulcer excision is an alternative to partial gastrectomy for surgically treating type I gastric ulcer.

Dysphagia and lower esophageal sphincter abnormalities after proximal gastric vagotomy.

We studied 96 patients subjected to elective proximal gastric vagotomy for intractable duodenal ulceration. Dysphagia was a frequent finding and occurred in 32 percent. It appeared in the immediate postoperative period and usually lasted for 1 to 2 months without any abnormalities in lower esophageal sphincter function. In five patients, dysphagia was severe and, although transient, was associated with changes in lower esophageal function simulating those observed in achalasia. The mechanism of these motor abnormalities is probably due to a reversible neuromuscular dysfunction of the lower esophageal sphincter.

Prospective, randomized trial of selective vagotomy with pyloroplasty and selective proximal vagotomy with and without pyloroplasty in the treatment of duodenal, pyloric, and prepyloric ulcers.

In a prospective, randomized trial, 161 patients with duodenal, pyloric, or prepyloric ulcer underwent selective proximal vagotomy. Randomization was then performed to determine if the operation was finished (52 patients), if a pyloroplasty should be added (56 patients), or in addition, if the nerves of Latarjet should be divided (53 patients). Prepyloric and secondary gastric ulcers were excised for microscopy; all were benign. Sex, age, site of ulcer, and duration and incidence of complications of the ulcer disease were similar for the three groups. There was one operative death. The postoperative complications did not differ for the three groups. Four patients were lost to follow-up. The average follow-up for the 156 patients was 3 years (range 1 to 8 years). Recurrent ulcer was detected up to 5 years after surgery in 4 of 53 patients who had selective vagotomy with pyloroplasty, in 4 of 53 who had selective proximal vagotomy with pyloroplasty, and in 5 of 50 who had selective proximal vagotomy. Diarrhea was rare and mild or absent. Dumping was twice as common after selective vagotomy or selective proximal vagotomy with pyloroplasty than after selective proximal vagotomy only, but dumping resistant to treatment was recorded in only two or three patients in each group. The overall results (modified Visick scale) were unsatisfactory in 7 patients after selective vagotomy with pyloroplasty, in 4 after selective proximal vagotomy with pyloroplasty, and in 10 after selective proximal vagotomy, mainly because of epigastric pain with or without recurrent ulcer. We conclude that pyloroplasty may cause mild dumping without nuisance to the patient. The rates of recurrent ulcer in long-term follow-up trials are essential for final evaluation of the operations.

Laparoscopic management of peptic ulcer disease.

Laparoscopic surgery has heralded a new era for the operative management of peptic ulcer disease. With a mean hospital stay of 3.5 days,22 a recurrence rate of 4% to 11%,1,3 and a morbidity from dumping and diarrhea of 1% to 2%,21 laparoscopic proximal gastric vagotomy can truly provide a good alternative to medical therapy. Despite the high cost of medical care and surgical equipment, a laparoscopic vagotomy should be cost effective compared with life-long pharmacologic management of peptic ulcer disease. Several different operative procedures have been discussed, with similar outcomes. The surgeon has a choice of several approaches, depending on his or her training and level of skill. As surgeons gain experience with laparoscopic surgery, we are able to offer consistently good results with low recurrence rates and negligible morbidity and mortality. Minimally invasive surgery has rekindled the operative treatment of peptic ulcer disease.

[Esophageal perforations after vagotomy]. / Osophagusperforationen nach Vagotomie.

Oesophageal perforation after vagotomy is a quite rare complication. We know figures between 0.4 and 0.8%. The radiodiagnostic verification has central significance for a possibly necessary reoperation, and hence the prognosis of the patient, if this perforation is not recognized under the operation, or necrosis of the wall should happen in the early post-operative phase. We give information about four own observations.

A composite score of enterogastric reflux quantitation on 99mTc-HIDA scintigraphy.

BACKGROUND/AIM: Enterogastric reflux of bile, and duodenal and pancreatic secretions may occur either spontaneously or, more commonly, after gastric surgery. The most reliable method in discriminating symptomatic from asymptomatic postgastric surgery refluxers, and in predicting a good clinical result after surgical diversion in the former group, is the quantitation of reflux by 99mTc-HIDA scintigraphy. MATERIALS AND METHODS: In 28 normal subjects and 143 postgastric surgery patients, the enterogastric reflux (EGR) was demonstrated by 99mTc-HIDA scintigraphy on 230 occasions. The EGR index was quantitated according to two different formulae: the former one based on the amount of refluxate (percentage of maximal radioactivity of the gastric area over the total abdominal activity--EGR-Im) and the latter one based on the amount and the duration of the time of reflux (CompEGR-Im) and representing the area of the surface below the curve, which was yield by plotting EGR-Im values (obtained every 5 min for one hour) against time. RESULTS: Although there was a highly significant correlation of values between the two methods (p<0.0000001), the latter one was more reliable in classifying postgastric surgery patients according to the presence of reflux symptoms and the reflux index. CONCLUSIONS: In patients with a CompEGRpIm>770 and postgastric surgery symptoms, at least some of the symptoms can be safely be attributed to enterogastric reflux.

Helicobacter pylori after surgery for duodenal ulcer.

BACKGROUND/AIMS: The role of Helicobacter pylori as a cause of peptic ulcer is still subject to controversy. The Kock's postulates have not been yet fulfilled; the bacteria can be found in normal persons, and it persists in the stomach after the ulcer is healed. MATERIAL AND METHODS: The authors analyzed 41 persons formerly submitted to surgery (after 8 years and 4 months, as a mean), 31 to highly selective vagotomy, and 10 to truncal or selective vagotomy plus gastroduodenal drainage. All of them were asymptomatic, or had symptoms not related to ulcer relapse. RESULTS: At endoscopy the ulcers were healed in all 41 individuals, and there was evidence of gastritis in three. The histopathological exam showed gastritis in all biopsy specimens. The search of H. pylori by urease method and by Giemsa staining was positive in 40. CONCLUSION: It was concluded that the gastric acid secretion reduced by vagotomy was the main factor to healing the ulcer, not subordinated to H. pylori.

Manifestation of severe dysphagia in patients with epiphrenic diverticula after proximal selective vagotomy.

Two patients suffering from epiphrenic diverticula developed severe disturbance of the esophagus following proximal selective vagotomy for duodenal ulcer.

[Effect of fundus vagotomy on the gastric emptying of the solids and liquids of a meal in patients with and without postoperative duodenal ulcer recurrence]. / Effet de la vagotomie fundique sur la vidange gastrique des solides et des liquides d'un repas chez des patients avec et sans récidive ulcéreuse duodénale post-opératoire.

The effects of fundic vagotomy (FV) on gastric emptying in the solid and liquid phases of a meal were studied by an isotopic technique in 12 patients with duodenal ulcer. Postoperative results were compared with those obtained in the same subjects before FV and with control values obtained in an identical group of healthy subjects. Early gastric emptying (perprandial) of the two phases of the meal was enhanced by FV but the results failed to reach statistical significance. Gastric emptying of liquids, measured during the 3 h following the end of the meal, was not significantly modified by FV (half-emptying times: 62 +/- 5 min before FV, 75 +/- 8 min after and 65 +/- 7 min for controls). That of solids was significantly delayed by FV (per cent emptied by min: 0.50 +/- 0.02 p. 100 before FV, 0.40 +/- 0.03 p. 100 after, and 0.49 +/- 0.02 p. 100 for controls); this delay was found in all but one patient, but the difference was very slight. Eleven of the 12 investigated patients cured by the operation, were compared with 6 subjects presenting with post FV recurrence: gastric emptying rates of solids (0.41 +/- 0.02 p. 100/min and 0.47 +/- 0.07 p. 100/min) and half emptying times of liquids (72 +/- 10 min and 61 +/- 10 min) were not significantly different. Thus, the gastric emptying rate of an ordinary meal remains practically unchanged by FV and postoperative recurrences of duodenal ulcer cannot be explained by alteration of gastric evacuation.

[Anatomopathologic changes in the distal esophagus following proximal gastric vagotomy. Experimental study]. / Cambios anatomo-patológicos en el esófago distal tras la vagotomía gástrica proximal. Estudio experimental.

In order to determine the causes of postvagotomy dysphagia, we examined microscopic changes in the lower esophagus after a proximal gastric vagotomy. Forty dogs were divided into 4 groups (n = 10). Group I was used as control. In group II, the effect of denervation was studied by means of transthoracic vagotomy. In group III, the effect of mechanical traction of the lower esophagus was studied, without denervation or surgical manoeuvres. In group IV, the effect of denervation, esophageal traction and the surgical manoeuvres, of proximal gastric vagotomy was examined. No periesophageal hematomas or fibrosis was found. Degenerative nerve phenomena were found with no significant differences in the three groups. In groups III and IV, lesions of the esophageal muscular layer were observed, without significant differences. Chronic inflammatory changes and fibrosis were also encountered being more intense and significantly more frequent in group IV. We conclude that the surgical manoeuvers necessary to obtain denervation of the cardioesophageal function during proximal gastric vagotomy, could be responsible for the appearance of post-vagotomy dysphagia.

Highly selective vagotomy in the treatment of peptic ulcer diathesis.

The results of highly selective vagotomy in 174 Indian patients have been analysed. Compared to other procedures on the stomach, HSV has a definite advantage both on long term as well as on short term basis. HSV has therefore become the procedure of choice in the treatment of duodenal ulcer disease provided the expertise is available locally. HSV has also been used now in the treatment of ulcer complications and benign gastric ulcer disease.

[Risk of carcinoma of the stomach after vagotomy]. / Riesgo de carcinoma gástrico tras vagotomía.

To evaluate the influence of vagotomy in the development of gastric carcinoma, we conducted a prospective, controlled study of 183 patients diagnosed of gastric or duodenal peptic ulcer resistant to medical treatment; all cases had been treated by oxyntic cell vagotomy, without drainage, in the Departamento de Cirugía del Hospital Universitario Virgen del Rocío, Sevilla. Once a year all patients were clinically, radiologically and endoscopically evaluated. In 149 patients followed during 14 years, we did not find any case of carcinoma or premalignant lesions. Therefore, our experience does not suggest that, in the absence of drainage, vagotomy constitutes a contributory factor in the development of gastric carcinoma.

[Early necrotic ulcer of the lesser curvature of the stomach following supraselective vagotomy. Apropos of a case]. / Ulcère nécrotique précoce de la petite courbure gastrique après vagotomie suprasélective. A propos d'un cas.

The authors report the case of a 29 years old man who, having been subjected to a highly selective vagotomy for a duodenal ulcer, developed a gastric ulcer at the upper small gastric curvature during the first days following the operation. This ulcer will become chronic, and cause after three years a severe digestive hemorrhage. Six years after the vagotomy, the ulcer will be treated by means of a subtotal gastrectomy. In consequence of this personal case, the authors reconsider the literature concerning the frequency, the pathogenesis, the characteristics and the treatment of this rare complication of the highly selective vagotomy.