A relic or still relevant: the narrowing role for vagotomy in the treatment of peptic ulcer disease.

BACKGROUND: Given the rise of medical treatment for peptic ulcer disease (PUD), surgical treatment is necessary only in select cases and emergencies. The authors assess the current relevance of surgical vagotomy to treat PUD and its complications. DATA SOURCES: Although historically significant, selective and highly selective vagotomy is very technically challenging, and highly selective vagotomy has a relatively narrow indication and high recurrence rates. Vagotomy and gastrectomy is associated with significant side effects. Two types of vagotomy remain relevant, within a narrow scope. Truncal vagotomy and pyloroplasty is safe and efficacious through a laparoscopic approach in certain emergent cases. Vagotomy and Roux-en-Y gastrojejunostomy can be used to treat severe PUD refractory to medical management. CONCLUSIONS: The role of vagotomy in the management of PUD has a rich history but predated pharmacologic control of acid and understanding of the role of Helicobacter pylori in the disease. Thus, the current role of vagotomy is significantly limited. Specifically, the emergent use of truncal vagotomy is warranted for patients who are either resistant or allergic to proton pump inhibitors.

Vagotomy.

Peptic ulcer disease was for years a common indication for surgery in Danish hospitals and considerable experience in partial gastrectomy was gained. In spite of an unquestionable mortality rate and a number of patients having postgastrectomy complaints, results were generally recognized as acceptable. Danish surgeons were for long reluctant to take up vagotomy and drainage as a primary ulcer operation, but when they did start a large number of procedures were performed. In fact, the use of this treatment culminated during two to three decades. However, on a basis of experiences from these years, Danish research contributed actively to the international evolution of the surgical vagotomy technique, the evaluation of clinical results and the studies of postoperative alterations in gastric physiology. References are selected from an extensive literature and are in no way complete.

The centenary of Lester Dragstedt--fifty years of therapeutic vagotomy.

Lester Reynolds Dragstedt was trained initially as a physiologist and subsequently became a surgeon. He achieved renown not only because of his intellectual and technical skills, but because he was able to utilize physiological principles to define the development of surgical procedures. A humble upbringing in Anaconda, Montana was followed by a scientific education in Chicago. His brief background in surgery was obtained during a two year period spent mostly in Vienna and Budapest. At the University of Chicago, he pioneered the development of therapeutic vagotomy in the treatment of peptic ulcer disease. His research interests were many and varied, ranging from the toxemia of intestinal obstruction to the quest for a pancreatic hormone which might regulate fat metabolism. After retiring as Chairman of Surgery at the University of Chicago, he assumed a research position in surgery at the University of Florida in Gainesville. Dragstedt was a creative scientist, a superlative clinical surgeon, and a teacher honored by his pupils. The example of his life confirms the benefit of scientific inquiry when applied to clinical and surgical practice.

Lester R. Dragstedt and his role in the evolution of therapeutic vagotomy in the United States.

The date October 22, 1993, marks the centenary of the birth of Lester R. Dragstedt. He emerged from humble roots of Swedish immigrant parents to become one of the pre-eminent surgical innovators of the twentieth century. Early in his scientific career, Dragstedt was profoundly influenced by another Swede, A. J. Carlson, who was initially employed as a Lutheran minister in Dragstedt's hometown of Anaconda, Montana. Carlson left the ministry for graduate school and later became chairman of The Department of Physiology at the University of Chicago. When Dragstedt finished his schooling, Carlson convinced him to attend the University of Chicago. In addition to Carlson, Dragstedt's research was influenced by many prominent physiologists and surgeons, including Pavlov and Latarjet. Their work, along with his own investigations, helped him both to formulate his hypotheses on the regulation of gastric acid secretion and to formalize the operation of truncal vagotomy. In 1943, Dragstedt initiated the clinical use of this procedure in North America. Although he studied his patients carefully and documented his results meticulously, the operation initially met with considerable resistance from both his medical and surgical colleagues. Over time, many other surgeons accepted vagotomy as a viable procedure and further modified his technique. The unique ability of Dragstedt to transfer his research studies to the development and implementation of rational surgical therapy remains an enduring example for the surgical profession.

Wittmoser's technique of thoracoscopic sympathectomy and vagotomy.

His extensive developmental and clinical work made Raimund Wittmoser a major trailblazer in endoscopic surgery from the 1950s on. His single-puncture technique for operative thoracoscopy permitted surgical interventions of peerless quality on the sympathetic and vagal nerves. His basic surgical principle was to achieve the greatest possible selectivity by a segmental approach to the sympathetic rami communicantes or the individual branches of the vagus nerve. Besides his extraordinary surgical skills, his particular achievement was the development of new instrumental and ancillary technologies for endoscopic surgery. In addition to the development of new endoscopes and imaging systems, his pressure-regulated CO2 insufflation system and low frequency cautery technique had major impact on the further development of endoscopic surgery. Finally, Wittmoser's surgical interventions in the autonomic nervous system were of outstanding quality and set standards still observed by thoracoscopic surgeons today.

The history of vagotomy.

The anatomic characteristics of the vagus nerve were described by Galen in the second century AD, and its physiology was studied by Pavlov almost a century ago. Therapeutic possibilities of vagal denervation of the stomach was explored by several surgeons in the first quarter of this century. The most auspicious effort was that of Latarjet. The rebirth of vagotomy in 1943 by Dragstedt was based on cumulative new data supporting the concept that vagal denervation should favorably influence the clinical course of duodenal ulcer. This now proved concept renders vagotomy in some form a basic part of all operations for duodenal ulcer. The Dragstedt operation, vagotomy and pyloroplasty, is particularly useful in cases of acute bleeding and obstruction. Vagotomy and antrectomy has the lowest ulcer recurrence rate. Parietal cell vagotomy has the lowest mortality and morbidity rates and is the procedure of choice in patients with uncomplicated, intractable duodenal ulcer.