Henry Ford Hospital Medical Journal Volume 22 Number 3 Laurence S. Fallis, M.D. Commemorative Article 9 Issue

9-1974 Vagotomy with Pyloroplasty or Antrectomy: A Comparison of Results in the Treatment of Duodenal Ulcer Richard L. Collier

John H. Wylie Jr.

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Recommended Citation Collier, Richard L. and Wylie, John H. Jr. (1974) "Vagotomy with Pyloroplasty or Antrectomy: A Comparison of Results in the Treatment of Duodenal Ulcer," Henry Ford Hospital Medical Journal : Vol. 22 : No. 3 , 149-152. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol22/iss3/9

This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp. Med. Journal Vol. 22, No. 3, 1974

Vagotomy with Pyloroplasty or Antrectomy

A Comparison of Results in the Treatment of Duodenal Ulcer

Richard L. Collier, MD* and John H. Wylie, Jr, MD**

DURING the past several decades, there have been changes in the surgical treatment of peptic ulcer. More knowl­ edge of the physiology of the stomach has given direction to these trends. Dur­ ing his many years of surgical practice, Dr. Laurence Fallis found the surgical During the years 1970-73, 776 operations treatment of peptic ulcer to be one of his were performed for the relief of duodenal chief interests. He was an early and ulcer. Truncal vagotomy was done in all cases, strong advocate of vagotomy in the and to this was added antrectomy in 92 cases treatment of duodenal ulcer. When the and pyloroplasty in 24 cases. In the followup, three-fourths of the patients in both groups trend was to remove an ever increasing said they were satisfied with the result. There amount of the stomach to reduce gastric were four recurrences in the smaller pyloro­ acid secretion, he recommended com­ plasty group. In this series, antrectomy with bining vagotomy with resection of less vagotomy appears to be the best operation for than half of the stomach. During the past duodenal ulcer disease. 20 years, the extensive subtotal gastric resection has nearly disappeared from the surgical scene and vagotomy with pyloroplasty has been popular. How­ ever, critical studies have shown that this more conservative procedure has not been ideal for the control of recurrent ulcer disease. The generally reported re­ currence rate is 10-15% and this is not acceptable, at least in good risk patients. The combined operation of vagotomy •Resident 1957-62, Staff 1962-67. and partial gastric resection or antrec­ tomy appears to be better. Doctor Fallis ••Resident, 1950-52, 1954-57, Staff 1957-68. recognized the value of this procedure and contributed to the development of Address reprint requests to Dr. Collier at Okemos Surgical Assts., P.C., 2243 West the technic that has made it a safe and Grand River Avenue, Okemos, Ml 48864 durable operation.

149 Collier and Wylie

There is voluminous literature on the used the Finney or Jaboulay type of subject of the surgical treatment of pep­ pyloroplasty with truncal vagotomy. The tic ulcer, and we will not attempt even to patients with postbulbar ulcerations did summarize it. The purpose of this paper not do well with pyloroplasty and vag­ is to present our experience in a series of otomy. We feel that antrectomy and 116 operations for duodenal ulcer done vagotomy is the procedure of choice in in the years 1970-73. Although the num­ these cases. bers are not statistically significant, we have formed some tentative impressions A majority of the patients in this study as to the relative value of the two proce­ had had chronic ulcer disease for a long dures we have used. time. Seventy-five percent of the pyloroplasty group and eighty-five per­ pyloroplasty and vagotomy were done cent of these who had antrectomy had in 24 cases and a standard antrectomy had symptoms for more than one year. and truncal vagotomy in 92 cases. All of About half had had trouble for more the operations were done by one or the than five years. Bleeding was the usual other of us and in almost every case, the complication which was the indication other assisted. Consequently, there has for operation in patients with symptoms been a high degree of uniformity in the for less than one year. surgical technic. Results We selected the operative procedure for complicated duodenal ulcer disease There was no surgical motality on an individual basis, attempting to in either group. In the followup pro­ choose the procedure which would pro­ cedure, the patients were given a com­ vide each patient with the best oppor­ prehensive questionnaire three months tunity for cure of his disease with the to two years after the operation. They lowest possible risk. With high risk pa­ were asked to report on the occurrence tients and those patients who did not of individual symptoms, and to "grade" have advanced disease, it appeared that their postoperative result according to a physiological operation preserving the the following criteria which are modified stomach would be ideal, and we per­ from the classification of Visick.'' formed a pyloroplasty and truncal vag­ otomy. I. Excellent - No symptoms, signs or problems. No limita­ At first, we used the Heinke-Mikulicz tion of activity. Able to type of pyloroplasty. A number of pa­ resume normal occu­ tients developed emptying problems pational duties. No and recurrent ulceration without any limitations in dietary apparent decrease in the dumping pattern. Satisfied with and/or diarrhea incidence as compared results of surgery. with the patients having gastric resec­ tion. In particular, we had difficulties in II. Good - Satisfied with results of those patients who had concomitant surgery. Few and occa­ cholecystectomy with pyloroplasty and sional minor symptoms vagotomy. Reoperation on several of or problems. Able to these patients demonstrated adherence resume normal occu­ of the duodenum and antrum to the in­ pational duties. Minor ferior aspect of the liver, creating a kink­ alterations in dietary ing effect which interfered with the emp­ pattern. No limitations tying of the antrum. We subsequently of activities.

150 Vagotomy with Pyloroplasty or Antrectomy

TABLE I The summary of the grading of func­ Functional Results (Visick) tional results after the two types of oper­ ations is shown in Table I. Pyloroplasty & Antrectomy & Vagotomy Vagotomy It was interesting to find that although (% of 25 cases) (% of 92 cases) a large number of patients continued to have one or more symptoms, more than I. Excellent 8% 31% three-fourths in each group were satis­ fied with the general postoperative re­ II. Good 68% 48% sult. Most of the patients had symptoms III. Fair 24% 16% infrequently and the symptoms were episodic, depending on dietary habits. IV. Poor 0 5% The dumping symptoms and diarrhea particularly fell into this group. Unre­ lenting difficulties which did not re­ spond to treatment occurred in less than 8%.

There has been no objective evidence of recurrence of ulcer disease in the pa­ III. Fair - Definite and frequent minor tients who had antrectomy and vag­ symptoms and prob­ otomy. In those who had pyloroplasty lems. Alteration in and vagotomy, 4 out of 24 had recur­ dietary pattern. Altera­ rence. Two of these patients have had a tion in activity level. second operation. Some incapacity in oc­ cupational duties. We have concluded that, in our hands, Some question about antrectomy with vagotomy is the best effectiveness of sur­ operation for duodenal ulcer in general. gery. When the age of the patient or general conditions may increase the operative IV. Poor - Constant and major symp­ risk, we do a Finney or Jaboulay pyloro­ plasty and vagotomy. toms and problems. Incapacity in occupa­ tional duties. Marked Acknowledgement limitation in activity The authors are grateful for assistance level. Marked altera­ in the follow-up studies given by Mrs. tion in dietary pattern. Barbara Given, RN, and her staff of the Unsatisfied with results Michigan State University School of of surgery. Nursing.

151 Collier and Wylie

References

1. Cox AG: A comparison of symptoms after 3. Herrington JL Jr.: Current trends in the vagotomy with gastrojejunostomy and par- treatment of duodenal ulcer. Surg Cynec rial gastrectomy. Brit Med J 1:288, 1968 Obstet 139:87, 1974

2. Goligher JC et al: Comparison of different 4. Visick AH: The study of failures after gas- operations. Chapter 8 in After Vagotomy, trectomy. Ann Royal Coll Surg 3:266, 1948 edited by Williams JA and Cox HG, New York, Appleton Century Crofts, 1969

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