Highly selective vagotomy without a drainage procedure in the treatment of haemorrhage, perforation, and pyloric stenosis due to peptic ulcer

Abstract

The good results of highly selective vagotomy (H.S.V.) in the elective surgical treatment of uncomplicated duodenal ulcer led to its use in the treatment of 30 patients who were suffering from complications of peptic ulcer, over a period of 21 months. In the emergency situation it is vital to select for H.S.V. patients who are fit enough to withstand a 1–2-hour operation. Five out of a total of 9 patients with perforated duodenal ulcer were deemed to be suitable for H.S.V. In contrast, H.S.V. was used in the treatment of all 10 patients with haemorrhage (5 patients with duodenal ulcer and 5 with gastric ulcer), because definitive treatment for the ulcer is essential after haemorrhage has been arrested by direct suture. Pyloric stenosis was diagnosed in 15 of 75 patients who came to elective surgery for duodenal ulcer. The diagnosis was made on clinical and radiological grounds and was confirmed at operation. Seven of the 15 patients had concomitant gastric ulceration. All 15 patients were treated by H.S.V. without a drainage procedure. The stenosis was simply dilated digitally. Seven patients who were followed up for at least a year underwent barium-meal examination, which showed that gastric emptying was normal in each case and that there was no sign of recurrent ulceration. There was no operative mortality. None of the patients with haemorrhage bled again after operation. Only 1 of the 30 patients developed gastric retention, which was transient. Of the 14 patients who were reviewed more than 1 year after H.S.V., 11 had a perfect clinical result, 2 were very good, and 1 was ‘fair’ (Visick grade 3). The long-term prognosis should be the same as that of patients who have undergone elective H.S.V. Granted a modicum of case selection, H.S.V. is a safe operation in the treatment of emergencies such as haemorrhage or perforation. In pyloric stenosis H.S.V. preserves and makes use of the stomach's compensatory mechanisms of hypertrophy and hyperperistalsis, whereas both gastrectomy and vagotomy with drainage destroy them. Vagotomy of the entire stomach makes necessary the addition of a drainage procedure. Vagotomy with drainage impairs the ability of the antrum to ‘mill’ food and to propel chyme onwards, and destroys or by-passes the pyloric sphincter. These surgical insults to normal gastric physiology harm the patient by producing dumping, diarrhoea, bilious vomiting, steatorrhoea, and gross elevation of serum gastrin. The main conclusion of this paper is that such harm can be avoided, because it is shown that even patients with pyloric stenosis can be treated by H.S.V. without a drainage procedure. The routine use of complete gastric vagotomy with a drainage procedure in the elective surgical treatment of duodenal ulcer is no longer justified.