Concurrent laparoscopic highly selective vagotomy with closure of duodenal ulcer perforations show good clinical results as primary repair alone.

OBJECTIVE: To compare clinical and operative results between laparoscopic primary repair (LPR) alone and LPR with highly selective vagotomy (LPR-HSV) in patients with duodenal ulcer perforation. METHODS: Clinical data from patients who underwent either LPR or LPR-HSV by resecting both sides of the neurovascular bundle using an ultrasonic or bipolar electrosurgical device for duodenal ulcer perforations, between 2010 and 2020, were retrospectively collected. Between-group differences in continuous and categorical variables were statistically analysed. RESULTS: Data from 184 patients (mean age, 49.6 years), who underwent either LPR (n = 132) or LPR-HSV (n = 52) were included. The mean operation time was significantly longer in the LPR-HSV group (116.5 ± 39.8 min) than in the LPR group (91.2 ± 33.3 min). Hospital stay was significantly shorter in the LPR-HSV group (8.6 ± 2.6 days) versus the LPR group (11.3 ± 7.1 days). The mean postoperative day of starting soft fluid diet was also significantly shorter in the LPR-HSV group (4.5 ± 1.4 days) than in the LPR group (5.6 ± 4 days). No between-group difference in morbidity rate was observed. The learning curve of the HSV procedure showed a stable procedure time after 10 operations. CONCLUSIONS: LPR with HSV may be a safe and feasible procedure for selective cases who are at high risk for ulcer recurrence.

Exploring the safety and efficacy of stomach-partitioning gastrojejunostomy with distal selective vagotomy versus conventional gastrojejunostomy with highly selective vagotomy for treating benign gastric outlet obstruction: study protocol for a randomised controlled trial.

INTRODUCTION: Benign gastric outlet obstruction (BGOO) severely impacts the quality of life of patients. The main treatment methods for BGOO include surgery and endoscopy, but both have significant drawbacks. Therefore, this study aims to explore the safety and efficacy of a new technique, to develop a new option for treating BGOO. METHODS AND ANALYSIS: This is an ongoing prospective, single-centre, single-blind randomised controlled trial. The study will be conducted from January 2022 to December 2025, and 50 patients will be enrolled. The participants will be randomly assigned in a 1:1 ratio to either the experimental (stomach-partitioning gastrojejunostomy with distal selective vagotomy) or control groups (conventional gastrojejunostomy with highly selective vagotomy). We will collect baseline characteristics, laboratory tests, auxiliary examinations, operation, postoperative conditions and follow-up data. Follow-up will last for 3 years. The main outcome is the incidence of delayed gastric emptying within 30 days after surgery. Secondary outcomes include the efficacy indicator (consisting of serum gastrin level, pepsinogen level, 13C breath test, gastrointestinal quality of life index, operation time, blood loss and postoperative recovery), a safety evaluation index (consisting of complications and mortality within 30 days after surgery) and follow-up data (consisting of the incidence of primary ulcer progression in 3 years after surgery, and the gastroscopy results in 1 and 3 years after surgery). ETHICS AND DISSEMINATION: This study was approved by the Ethics Committee of Beijing Friendship Hospital, Capital Medical University (no. 2021-P2-274-02). The study conformed to the provisions of the Declaration of Helsinki (as revised in 2013). Written informed consent will be obtained prior to study enrolment. The results of this study will be published in peer-reviewed publications. TRIAL REGISTRATION NUMBER: ChiCTR2100052197.

The natural history of perforated foregut ulcers after repair by omental patching or primary closure.

BACKGROUND: The treatment of perforated foregut ulcers by omental patching (OP) or primary closure has mostly replaced vagotomy and pyloroplasty/antrectomy (VPA). We sought to determine the natural history and recurrence rate of ulceration in patients treated by omental patching or primary closure. STUDY DESIGN: An 11-year retrospective study. RESULTS: From 2004 through 2015, 94 patients had perforated foregut ulcers, 53 gastric, and 41 duodenal. 77 (82%) were treated by OP alone (study group) and 17 (18%) were treated with VPA (comparison group). All OP patients were discharged on PPIs, but only 86% took the drugs for a median of 22 months (1-192, SD 40). Endoscopy in the OP group showed recurrent ulcers in nine (12% recurrence rate) and gastritis in three (4%) This group also had three later recurrent perforations. Another recurrent ulcer hemorrhaged causing death (3% late mortality). Two other patients required non-emergent re-do ulcer operations for recurrent disease/symptoms (surgical re-intervention rate 4%). Total length of follow-up was median 44 months (1-192, SD 40) and was complete in 82 (87%). 18 (23%) patients in the OP group developed recurrent abdominal pain attributed to ulcer disease during follow-up, compared to 2 (12%) in the VPA group (p = 0.15). No patient in the VPA group had an endoscopic recurrence or re-intervention. CONCLUSION: Omental patching does not correct the underlying disease process which causes foregut perforation, and has a 12% endoscopically proven recurrent ulceration rate and a 23% incidence of recurrent symptoms within 44 months. Patients tend to stop taking PPIs after 22 months at which time their risk increases.

Nesfatin-1 modulates murine gastric vagal afferent mechanosensitivity in a nutritional state dependent manner.

Food intake is regulated by vagal afferent signals from the stomach. Nesfatin-1 is an anorexigenic peptide produced within the gastrointestinal tract and has well defined central effects. We aimed to determine if nesfatin-1 can modulate gastric vagal afferent signals in the periphery and further whether this is altered in different nutritional states. Female C57BL/6J mice were fed either a standard laboratory diet (SLD) or a high fat diet (HFD) for 12 weeks or fasted overnight. Plasma nucleobindin-2 (NUCB2; nesfatin-1 precursor)/nesfatin-1 levels were assayed, the expression of NUCB2 in the gastric mucosa and adipose tissue was assessed using real-time quantitative reverse-transcription polymerase chain reaction. An in vitro preparation was used to determine the effect of nesfatin-1 on gastric vagal afferent mechanosensitivity. HFD mice exhibited an increased body weight and adiposity. Plasma NUCB2/nesfatin-1 levels were unchanged between any of the groups of mice. NUCB2 mRNA was detected in the gastric mucosa and gonadal fat of SLD, HFD and fasted mice with no difference in mRNA abundance between groups in either tissue. In SLD and fasted mice nesfatin-1 potentiated mucosal receptor mechanosensitivity, an effect not observed in HFD mice. Tension receptor mechanosensitivity was unaffected by nesfatin-1 in SLD and fasted mice, but was inhibited in HFD mice. In conclusion, Nesfatin-1 modulates gastric vagal afferent mechanosensitivity in a nutritional state dependent manner.

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.

Highly selective vagotomy and gastrojejunostomy in the treatment of peptic ulcer induced gastric outlet obstruction.

BACKGROUND/AIM: The incidence of peptic ulcer-induced gastric outlet obstruction is constantly declining. The aim of this study was to present our results in the treatment of gastric outlet obstruction with highly selective vagotomy and gastrojejunostomy. METHODS: This retrospective clinical study included 13 patients with peptic ulcer-induced gastric outlet obstruction operated with higly selective vagotomy and gastrojejunostomy. A 3-year follow-up was conducted including clinical interview and upper gastrointestinal endoscopy on 1 and 3 years after the surgery. RESULTS: The most common preoperative symptom was vomiting (in 92.3% of patients). The mean preoperative body mass index was 16.3 +/- 3.1 kg/m2, with 9 patients classified preoperatively as underweight. There were no intraoperative complications, nor mortality. At a 3-year follow-up there was no ulcer recurrence. Delayed gastric emptying was present in 1, bile reflux in 2, and erosive gastritis in 1 patient. Two patients suffered from mild "dumping" syndrome. CONCLUSION: Higly selective vagotomy combined with gastrojejunostomy is a safe and easily feasible surgical solution of gastric outlet obstruction induced by peptic ulcer. Good functional results and low rate of complications can be expected at a long-term follow-up.

The gastric mucosa 25 years after proximal gastric vagotomy.

OBJECTIVE: Vagotomy causes inhibition of basal and post-prandial acid secretion in humans, but the knowledge about the trophic effect of the vagal nerves is limited. Vagotomy is known to induce hypergastrinemia and we aimed to study the long-term effects of proximal gastric vagotomy (PGV) on the oxyntic mucosa and the enterochromaffin-like (ECL) cell density in particular. MATERIAL AND METHODS: Eleven patients operated with PGV because of duodenal ulcer and age- and sex-matched controls were examined 26 to 29 years postoperatively by gastroscopy with biopsies from the antrum and oxyntic mucosa. Neuroendocrine cell volume densities were calculated after immunohistochemical labeling of gastrin, the general neuroendocrine cell marker chromogranin A (CgA) and the ECL cell marker vesicular monoamine transporter 2 (VMAT2). Gastritis was graded and Helicobacter pylori (H. pylori) status was determined by polymerase chain reaction of gastric biopsies. Fasting serum gastrin and CgA were measured. RESULTS: Serum gastrin was higher in the PGV group compared to controls (median 21.0 [interquartile range (IQR) = 22.0] pmol/L vs 13.0 [IQR = 4.0] pmol/L, p = 0.04). However, there was neither a significant difference in serum CgA or in CgA (neuroendocrine) nor VMAT2 (ECL cell) immunoreactive cell volume density in the oxyntic mucosa. There was significantly more inflammation and atrophy in H. pylori-positive patients, but PGV did not influence the grade of gastritis. CONCLUSION: Despite higher serum gastrin concentrations, patients operated with PGV did not have higher ECL cell mass or serum CgA. Vagotomy may prevent the development of ECL cell hyperplasia caused by a moderate hypergastrinemia.

[The choice of resection volume by the combination of perforative duodenal ulcer with other complications of the ulcer disease].

Treatment results of 59 patients with the complicated ulcer disease were analyzed. Authors prove, that in cases of perforative duodenal ulcer, the operation should aim the treatment of all the complications. The use of 2/3 gaster resection in combination with Jadd pyloroplasty and trunk vagotomy led to the decrease of the lethality rate on 21%.

Lipid-rich enteral nutrition regulates mucosal mast cell activation via the vagal anti-inflammatory reflex.

Nutritional stimulation of the cholecystokinin-1 receptor (CCK-1R) and nicotinic acetylcholine receptor (nAChR)-mediated vagal reflex was shown to reduce inflammation and preserve intestinal integrity. Mast cells are important early effectors of the innate immune response; therefore modulation of mucosal mast cells is a potential therapeutic target to control the acute inflammatory response in the intestine. The present study investigates intestinal mast cell responsiveness upon nutritional activation of the vagal anti-inflammatory reflex during acute inflammation. Mucosal mast cell degranulation was induced in C57/Bl6 mice by administration of Salmonella enterica LPS. Lipid-rich enteral feeding prior to LPS significantly decreased circulatory levels of mouse mast cell protease at 30 min post-LPS compared with isocaloric low-lipid nutrition or fasting. CCK-1R blockage reversed the inhibitory effects of lipid-rich feeding, whereas stimulation of the peripheral CCK-1R mimicked nutritional mast cell inhibition. The effects of lipid-rich nutrition were negated by nAChR blockers chlorisondamine and α-bungarotoxin and vagal intestinal denervation. Accordingly, release of ß-hexosaminidase by MC/9 mast cells following LPS or IgE-ovalbumin complexes was dose dependently inhibited by acetylcholine and nicotine. Application of GSK1345038A, a specific agonist of the nAChR α7, in bone marrow-derived mast cells from nAChR ß2-/- and wild types indicated that cholinergic inhibition of mast cells is mediated by the nAChR α7 and is independent of the nAChR ß2. Together, the present study reveals mucosal mast cells as a previously unknown target of the nutritional anti-inflammatory vagal reflex.

Is Jaboulay gastroduodenostomy effective for treating duodenal stricture due to duodenal ulcer in the early postoperative term? Clinical consideration.

BACKGROUND/AIMS: Indications for surgery in patients with duodenal ulcers have changed radically. Gastric outlet obstruction (GOO) is a complication that can result from duodenal ulcers. From the perspective of organ preservation, gastroduodenostomy (e.g. Jaboulay procedure) is ideal for the treatment of GOO due to duodenal ulcer-induced stricture; however, delayed gastric emptying is frequently observed postoperatively. We compared the short-term clinical outcomes of Jaboulay procedure with those of antrectomy. METHODOLOGY: We retrospectively studied 30 patients who underwent surgery for GOO due to duodenal ulcer. The patients were divided into the J group (those who underwent highly selective vagotomy with Jaboulay gastroduodenostomy) and the A group (those who underwent highly selective vagotomy and antrectomy with Billroth II reconstruction). RESULTS: The mean duration of nasogastric suction, number of days until diet initiation, number of days until oral ingestion of solid food and postoperative duration of hospitalization were significantly shorter in the A group than in the J group. Moreover, delayed gastric emptying was significantly less frequent in the A group than in the J group. CONCLUSIONS: Considering the short-term postoperative outcomes, we believe that highly selective vagotomy and antrectomy with Billroth II reconstruction are the preferred procedures for duodenal ulcer-induced GOO.

[Surgical treatment of gastroduodenal ulcers according to principles of a modern antirecurrence therapy with postoperative complications prophylaxis].

Modern approaches to surgical treatment of gastroduodenal ulcers in accordance with principles of antirecurrence therapy, directed on prophylaxis of postoperative complications occurrence, are enlighted.

[Erik Amdrup (1923-1998): The life and times of the Danish surgeon and author]. / Der dänische Chirurg Erik Amdrup (1923-1998) Schriftstellerarzt und gastroenterologischer Forscher.

The Danish professor, surgeon, medical superintendent, researcher and writer of fictional literature Erik Amdrup is one of the inventors of the parietal cell vagotomy. He carried out many internationally acclaimed research projects about the surgical treatment of gastric and duodenal ulcer. At the same time he witnessed the changes in the conditions at the Danish hospitals. He used his professional experiences in his prose and his memoirs. They give an insight into the younger Danish history of medicine.

Pathophysiology and modern treatment of ulcer disease.

This is an overview of the pathophysiological abnormalities of gastroduodenal (GD) ulcers [duodenal ulcer (DU), gastric ulcer (GU) and Dragstedt ulcers (combined DU and GD)], as well as the effects of the different treatments (surgical, medicinal and physiological) described since the introduction of stomach resections. The intention is to demonstrate whether the peptic ulcer diseases are a homogeneous entity with a characteristic pathophysiology or whether they represent the final expression of many heterogeneous causes including impairment of upper gastrointestinal motility. The review also asks whether DU and GU have a common or different pathogenesis and whether ulcers in the stomach might be predominantly due to impaired mucosal resistance and the DU to gastric hypersecretion. The symptoms of both diseases are also compared with the findings in the normal controls.

[Characteristics of the fundoplication in patients with shortened esophagus].

Antireflux surgery in recent years become a standard treatment for complicated forms of gastroesophageal reflux disease (GERD). Complicated forms of GERD are usually the result of the availability of hiatal hernia (HH). Acquired shortening of the esophagus is a natural complication of severe reflux esophagitis developing on a background of sliding HH. Among surgeons disagree about the appropriateness of the laparoscopic antireflux interventions for patients with a shortening of the esophagus. On the basis of the Central Research Institute of Gastroenterology 35 patients were performed to laparoscopic surgery by truncation of the esophagus. Analysis of results showed the efficacy and safety of laparoscopic access for treatment of reflux esophagitis in patients with the esophagus truncation.

[An integrated approach to diagnosis and treatment of Barrett's esophagus].

Barrett's oesophagus is a condition when the oesophagus adenocarcinoma risk increases. There are different ways of diagnostic and treatment for this disease abroad and our country. We offer a complex method for Barrett's oesophagus treatment. Our method reveals Barrett's oesophagus effectively. We also take antireflux treatment and Barrett's epithelium elimination using miniinvasive surgery with drugs therapy. We have experience of curing 48 patients from Barrett's oesophagus. Considering obtained results our tactic for clinical practice is recommended.

[Surgical treatment of hiatal hernias].

17 patients suffering from axial hiatal hernias with marked duodenogastroesophageal reflux underwent surgical treatment including selective proximal vagotomy combined with formation of closing cardia mechanism, enhancement in are flux function of pylorus, correction of duodenostasis. Specific postoperative complications and lethal outcomes were not observed. Increase of life quality was observed among patients in early and long-term postoperative periods in comparison with preoperative indices. Relapses or regurgitation disturbances were not observed either.

[Immunomodulation and systematic enzymotherapy during surgical treatment of the duodenal ulcers].

The aim of our investigation was to study the influence of the systematic enzymotherapy on the results of surgical treatment of patients with duodenal ulcers. The immunological investigation was conducted on 77 patients with duodenal ulcers. The obtained results reveal the changes of immunological indexes in patients with duodenal ulcers. The process of rehabilitation with immunomodulative and enzymatic therapy after surgical treatment is analyzed and described.

Late results of the surgical treatment of 125 patients with short-segment Barrett esophagus.

HYPOTHESIS: The results of surgical treatment of patients with long-segment Barrett esophagus (BE) have been extensively reported. However, few publications refer to the results of surgery 5 years after the fact among patients with short-segment BE. This study aimed to determine the late results of 3 surgical procedures in patients with short-segment BE by subjective and objective measurements. DESIGN: Prospective, nonrandomized study starting on March 1, 1987, and ending on December 31, 2005. SETTING: A prospective, descriptive study of a group of patients. PATIENTS: A total of 125 patients with short-segment BE underwent 3 operations in different periods: duodenal switch plus highly selective vagotomy and antireflux technique in 31 patients, vagotomy plus partial gastrectomy and Roux-en-Y loop with antireflux surgery in 58 patients, and laparoscopic Nissen fundoplication in 36 patients. MAIN OUTCOME MEASURES: Late subjective and objective outcomes of the 3 different surgical procedures. RESULTS: No operative mortality and only 2 postoperative complications (1.6%) occurred. The regression from intestinal metaplasia to cardiac or oxyntocardiac mucosa occurred in 60.8% to 65.4% of the patients, at a mean time of 39 to 56 months after surgery. Visick grading showed Visick grade I or II in 86.3% to 100.0% of the patients. No progression to low- or high-grade dysplasia or adenocarcinoma occurred. CONCLUSIONS: On the basis of these results, laparoscopic Nissen fundoplication seems to be the surgical option for patients with short-segment BE because it is less invasive, has fewer side effects, and produces good results in the long-term follow-up.

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.

[Method of gastric drainage in connection with vagotomy in treatment of complicated posbulbar ulcers].

New surgical technique for treatment of "low" duodenal ulcers--transversal posterior retrocolic gastroenteroanastomosis with selective proximal vagotomy--was worked out and introduced by the authors. 78 patients (61 men and 17 women at the age of 14-76 years) with "low" duodenal ulcers were operated using this technique during 1982-2007 years. Short-term and long-term results of treatment were studied. Advantages of this technique and indications for the operations were determined. Obtained results indicate that this surgical approach is reliable and effective and can be applied in clinical practice.