Henry Ford Hospital Medical Journal

Volume 25 | Number 1 Article 6

3-1977 Early vagotomies at Henry Ford Hospital: An historical vignette and a follow-up James C. Gruenberg

Conrad R. Lam

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Recommended Citation Gruenberg, James C. and Lam, Conrad R. (1977) "Early vagotomies at Henry Ford Hospital: An historical vignette and a follow-up," Henry Ford Hospital Medical Journal : Vol. 25 : No. 1 , 37-44. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol25/iss1/6

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 25, No 1, 1977

Early vagotomies at Henry Ford Hospital An historical vignette and a follow-up

James C. Gruenberg, MD* and Conrad R. Lam, MD**

Over a one-year period beginning in IN April 1946, the speaker at the evening April, 1946, nine transthoracic vagotomies meeting of the Henry Ford Hospital Medical were done at the Henry Ford Hospital. Three Society was Dr. Lester Dragstedt of Chicago. of the patients had had a partial gastrectomy His subject was the "hot one" of the surgical previously and the operation was done for scene, "Vagotomy for Peptic Ulcer." There recurrent bleeding from marginal ulcers. was standing room only in the auditorium- Thirty years later, an attempt was made to gymnasium of the old Education Building. A ascertain the present condition of these pa­ late arrival was a surgeon who had come 200 tients. Long term follow-ups were possible miles from Grand Rapids, but the most inter­ on six patients and follow-ups of one, six and ested listener was a young doctor who was 14 years on the others. All nine patients had an inpatient at the time. He was suffering immediate relief of ulcer pain and cessation from a marginal ulcer, which followed a of bleeding if present. No subsequent drain­ previous partial gastric resection for bleed­ age operation was required for the six pa­ ing ulcer. He was impressed with Dragstedt's tients with primary vagotomy and no presentation, and requested that he have a additional operations were done on the vagotomy. It was done the next day Within a three patients with previous surgical pro­ year, eight other patients with peptic ulcers cedures. Late recurrent bleeding was noted received the operation and are the basis of in only one patient (who had had two pre­ this study: a 30-year follow-up of these first vious gastric operations), and recurrence of vagotomies at the Henry Ford Hospital and ulcer symptoms in the others was rare and of probably in Michigan. mild degree. In an attempt to explain why "pure" vagotomy did not continue to be Most bibliographies ofthe subject of vago­ recommended for the surgical treatment of tomy begin with a paper by Dragstedt and peptic ulcer, a review is presented of signifi­ Owens, which was published in 1943 in the cant reports from important surgical centers Proceedings of the Society of Experimental during the ten years which followed. Biology and Medicine,'' a journal whose contents consist mostly of laboratory re­ search reports. The choiceofthejournal was undoubtedly influenced by the fact that * Division 1, General Surgery Dragstedt was a practicing physiologist as •'Division of Thoracic and Cardiovascular well as a surgeon, and the Proceedings Surgery provided a medium for rapid publication of new work. This report was followed Address reprint requests to Dr. Conrad Lam, Divi­ promptly by papers in five leading clinical sion of Cardiovascular Surgery, Henry Ford Hospi­ tal, 2799 West Grand Boulevard, Detroit, Ml journals,^"^ and vagotomy was on its way. 48202. Although Dragstedt is generally credited

37 Gruenberg and Lam with originating vagotomy the veteran gas- patients, and this never persisted for more troenterologist and editor Walter C. Alvarez than four weeks. In the last column ofTable I, was able, in 1948, to write a paper with the it is mentioned that this patient (a physician) title "Sixty Years of Vagotomy: A Review of developed diarrhea six years after the vago­ Some 200 Articles."^ tomy and seven years after partial gastric resection. He had many greasy stools and the diagnosis of non-tropical sprue was The vagotomies on the nine patients of made. In 1957, or 11 years after the vago­ Henry Ford Hospital were done by one of us tomy, he developecf a peculiar syndrome of (Conrad R. Lam, MD) by the transthoracic pain in the muscles of the legs and some route. The chest was entered through the parathesias. There was never any explana­ seventh left interspace. The mediastinal tion for what was tentatively called "poly­ pleura was opened to expose the lower myositis" or "peripheral neuritis." It was esophagus which was mobilized, and both wondered if his sprue-like trouble with poor vagus nerves were visualized. Segments of digestion of fat and meat could have some the nerves were removed and the proximal etiologic bearing. An incomplete follow-up ends of the nerves were directed cephalad indicates that the patient has had no further and were sutured outside the mediastinum trouble relating to his ulcer problem, and is to preclude any possibility of regeneration practicing as a physician in a southern state. and restoration of continuity of the nerves.

On the other and more positive side of the Table 1 has two columns of results, one for ledger, the following statements can be the "immediate result" and another for the made regarding these nine patients with long-term result. For an evaluation of the vagotomy. All patients were immediately immediate result, one would be more inter­ relieved of ulcer pain, and bleeding, if pres­ ested in the possible occurrence of side ent, ceased. No patient had a subsequent effects than in the near-term relief of pain operative procedure. Recurrent bleedingoc- and bleeding. A tendency to gastric atony curred in only one patient (Case 2), and he was expected and treated by nasogastric had had two operations on the stomach, a drainage for several days. At the time of gastroenterostomy 40 years before the vago­ discharge from the hospital, most of the tomy, and a partial gastric resection 11 years patients had less than 10% retention of the before. barium meal. Persistent symptoms of de­ layed emptying were present only in the young man (Case 7) who went to Okinawa Gastric analyses very shortly after his operation. Because of recurrent vomiting, he was evacuated back All ofthe nine patients had pre- and post­ to the base hospital in Tacoma, Washington, operative gastric analyses for hydrochloric where upper gastrointestinal x-ray studies acid. All showed a reduction, but there was were negative except for deformity of the no correlation between the evidence of the duodenal bulb. He was pronounced fit for degree of vagotomy and the clinical re­ return to duty and a letter from him stated sponse, which was good in all nine. that he was on his way back to Guam. He summarized his army duty as follows, "up to now I've had a very enjoyable vacation with Discussion two sea voyages and it hasn't cost me too A follow-upof these nine cases atone year much." Unfortunately, no further follow-up or three years would have indicated that was possible on this young man. vagotomy alone or as an addition to a pre­ vious partial gastrectomy is good treatment The postoperative notes mention diarrhea or forthe ulcer patient. So would this follow-up increased frequency of stools in only four after 30 years. Why then was vagotomy as

38 TABLE I Data On Nine IMale Peptic Ulcer Patients With Vagotomy In 1946 Series Duration of Immediate Years Subsequent History Number Initials Age Symptoms (yrs.) Remarks Result Follow-Up and Present Status 1. R.v.H. 24 3 Gastric resection in Excellent; no further 30 Late period of diarrhea 1945; recurrent bleeding. ? Sprue; working as a bleeding. physician. 2. CM. 60 30 Gastroenterostomy in Excellent; mild 21 Bleeding 2 years and 10 1916; gastric resec­ diarrhea one month. years p.o.; died of tion in 1935; recur­ leukemia at age 81. rent bleeding. 3. PF 27 10 Very nervous; heavy Excellent; dysptiagia 6 Episode of pain 2 years smoker. & mild diarrtiea4 wks. p.o.; deserted family in 1952; no follow-up.

4. 01 J.B. 27 4 Referred by self Excellent. 29 No further ulcer symptoms; -t after reading about film in 1975, negative; -< Dragstedt lecture. advised to stop smoking. <; Gl consultant advised medical treatment. o 5. S.S. 45 23 Several episodes of Excellent. 26 No symptoms in 1972; 3 bleeding; heard diabetic; lost to follow- Dragstedt's lecture up. and wrote him. 6. V.R. 32 6 Ulcer crater present. Excellent. 14 No symptoms in 1960; lost to follow-up. 7. D.W. 34 5 Duodenal cap Gastric retention 50% 1 Evacuated from Okinawa; deformed. at 4 wks. Left for mild retention; discharg­ Okinawa. ed from Army Hospital as O.K. 8, H.S. 51 18 One episode of Excellent. 30 Episode of pain after bleeding. "several years" and in 1974; managed medically. 9. W.K. 58 14 Bleeding for 6 years; Excellent. 19 Stroke with aphasia in gastric resection in 1965 at age 77. 1942; recurrent bleeding. Gruenberg and Lam the primary surgical procedure given up at of time and careful study of the patients the Henry Ford Hospital and other centers? operated on at this and other clinics." By March of 1947, he could report that 84 patients had had the operation, and the The most logical explanation is that the clinical results of 74 had been evaluated. He results in this small series were better than in summarized by saying that "satisfactory re­ other and larger series. sults have been obtained in approximately 90 per cent of the cases. A poor result may The status of vagotomy with American be due to difficulty with the ulcer, but may surgeons in the Spring of 1947 is well re­ also occur when side-effects are of a massive flected in a symposium of four papers pre­ and crippling type; the minor gastrointesti­ sented at the annual meeting of the nal side-effects are not vitiated by the per­ American Surgical Association at Hot formance of gastroenterostomy. Good Springs, Virginia. Dragstedt' was given the results have been obtained in patients who last word, not only in the line-up of papers were intractable to all forms of therapy but in the discussion. The title of the paper including subtotal gastrectomy. Vagus sec­ by Waltman Walters and his associates' from tion is an addition to the surgical armamen­ theMayo Clinic was "A Study ofthe Results, tarium which may come to occupy a Both Favorable and Unfavorable, of Section permanent and important place. A reserved of the Vagus Nerves in the Treatment of attitude must be maintained until the present Peptic Ulcer." Walters had personally done groups of patients have been followed the operation of "gastric neurectomy" as he longer..." preferred to call it 40 times. Twenty-eight patients had duodenal ulcer, seven had gas- trojejunal ulcer (hence had a previous resec­ The third paper presented by R. Arnold tion) and five had gastric ulcers. Only 14 Griswold'^ of Louisville consisted mainly of cases had vagotomy alone; in 13 of these, the the presentation of laboratory studies in 34 results were satisfactory as measured by cases. However, in hisclosingdiscussion, he relief of pain, reduction of acidity and reduc­ said, "I will simply say that the results have tion of secretions. There was disturbance in been satisfactory to us and to the patients motility with gastric retention in 4 of 10 with about the same ratio of good results and duodenal ulcer patients. He said "among the side effects as presented by the other patients who had gastrojejunal ulcers, im­ speakers." mediate results of the operation have been very satisfactory." The results for gastric In the final paperof the symposium, Drag- ulcers were less satisfactory. Walters con­ stedt° said that 212 vagotomies had been cluded, "for the time being, the operation of done at the University of Chicago, and the gastric neurectomy must be considered to be results in 160 of these has been analyzed for in the investigative stage and the effects of the meeting. There had been only one death, the operation carefully studied." and that was from aspiration pneumonia. In 142, studies indicated that the vagotomy had been complete. At this time, he was recom­ Francis D. Moore'" gave a follow-up re­ mending the transabdominal approach, so port on the cases at the Massachusetts Gen­ that if cicatricial stenosis of the pylorus was eral Hospital, a preliminary report having found, a gastroenterostomy could be done. been given on 12 cases the year before in the He did not say how many times he had done New England Journal of Medicine.'''' The a drainage procedure. There were only five latter paper had among its conclusions, "this instances of ulcer symptoms, and he at­ procedure appears to be a potent weapon in tributed these to incomplete vagus section. dealing with peptic ulceration, as judged by clinical results in these early follow-ups. The The four papers were followed by consid­ value of this method must await the passage erable discussion, which occupied 10 pages

41) Early vagotomies

in the Annals of Surgery. Crimson of Duke followed seven years. In a paper presented University had done 77 vagotomies. He before the Section on Surgery, General and noted that with few exceptions healing or Abdominal, ofthe American Medical Asso­ quiescence of ulcer occurred. However, he ciation in June, 1950, Dragstedf gave the had had to do seven secondary gastroen­ following summary: "From an appraisal of terostomies, and his group was employing 509 vagotomy operations for peptic ulcer at subdiaphragmatic vagotomy with the University of Chicago Clinics between pyloroplasty, exclusion or gastrojejunos­ January 1943 and January 1950the following tomy for duodenal ulcer, reserving vago­ conclusions have been drawn: tomy alone for stomach ulcer. Colp of New York also had done 77 cases. Fearing an 1. "Complete vagotomy by a transab­ increasing incidence of gastrojejunal ulcer, dominal transdiaphragmatic ap­ he said his treatment for duodenal ulcer proach, combined with a would be gastric resection and vagotomy gastroenterostomy of small size, is a Good results had followed vagotomy for 12 relatively safe, efficient and practical patientswith gastrojejunal ulcer. He did not method of surgical treatment and agree with Crimson that transthoracic vago­ should replace subtotal gastrectomy tomy was indicated for gastric ulcer, because as the initial definitive surgical treat­ he feared that malignancy might be present. ment for duodenal, gastrojejunal, and Dr. Frank Lahey uttered the same word of certain esophageal ulcers, caution about gastric ulcers, and said "We would like to select a series of uncompli­ 2. "The complications of vagotomy op­ cated duodenal ulcers in which we could do erations for peptic ulcer are chiefly a transthoracic vagotomy without the need due to motor disturbances in the of other complicating operations such as stomach and are for the most part gastroenterostomy, with the hope that we trivial and self limited and can be could eventually interpret for ourselves the controlled or eliminated entirely by value of this procedure." gastroenterostomy and adequate postoperative decompression of the Thorlakson reported that at the Winnipeg stomach. Clinic they had done 39 vagotomies. The immediate results had been excellent, and 3. " Persistence or recurrence of duode­ side effects had not been serious. Edwin nal or gastroduodenal ulcer is almost Miller of Chicago reported that his group invariably due to incomplete vago­ was pleased with the results in 40 cases. tomy, as evidenced by physiological Wangensteen said that after Waltman Wal­ tests." ter's talk on vagotomy in St. Paul, enthusi­ asm for the procedure had definitely waned By 1951, Waltman Walters'^ of the Mayo in the Twin Cities! In his closing remarks to Clinic was able to report on their experi­ the symposium, Dragstedt answered some ences with 331 vagotomy operations. Some questions which had been raised about the ofthe tables in the rather detailed report give pathophysiology of ulcer and the phys­ the results of 2,558 cases collected for the iologic effects of vagotomy. It is likelythat he American Gastroenterological Association felt that vagotomy as an adjunct in the by Dr. Sara Jordan ofthe Lahey Clinic. The surgical treatment of ulcer had survived the following are quoted from the two and a half rigors of discussion by his peers in the page summary: "After treatement of duode­ American Surgical Association! nal ulcer with vagotomy alone, 29 patients were followed one to four years. Excellent Four years later, the participants in the results were obtained in 62.1%, unsatisfacto­ symposium on vagotomy presented progress ry results in 31.0%, and poor results in 6.9%. reports. By this time, some patients had been When vagotomy was combined with gas-

41 Gruenberg and Lam troenterostomy for duodenal ulcer, results in nal Ulcer: A Final Survey after Ten Years." 81 patients followed one to four years were The study involved 132 patients. In 82 pa­ excellent in 81.4%, unsatisfactory in 12.4%, tientswith vagotomy alone, 31 had excellent and poor in 6.2% ... There is little evidence results, 21 satisfactory results, 3 had vagal in our small series to indicate that vagotomy symptoms and 6 had ulcer symptoms. The adds anything to gastroenterostomy in the results with 36 patients who had vagotomy prevention of gastrojejunal ulcer, although it and gastroenterostomy were excellent in 17, does produce lowering of gastric acidity in satisfactory in 9, and one each had vagal or almost all cases and to an achlorhydric level ulcer symptoms. Fourteen patients had vago­ in some. In fact, in some patients trouble­ tomy and subtotal gastrectomy. Ten had some postoperative retention has prolonged excellent results, 2 satisfactory results, and 1 hospitalization, increased the expense of patient had vagal symptoms. Their summary maintaining the fluid and electrolyte bal­ and conclusions: ance and made necessary excessive and constant care by resident surgeons and at­ "Vagotomy alone is not a satisfactory tending nurses. primary surgical procedure for duodenal ulcer when competing with subtotal gastrec­ "Vagotomy and gastric resection in nine tomy carried out in competent hands and cases of duodenal ulcer gave excellent re­ with low mortality. sults in 55.5% and unsatisfactory results in 44.5%. There were no suspected or proved "The efficacy of vagotomy combined with recurrences of ulcer in this group. However, posterior gastroenterostomy in the treatment because of associated postoperative vagal of duodenal ulcer is not supported by our symptoms, ft is felt that vagotomy probably data. Judgement must be reserved because was a detriment to gastric resection alone. ofthe high incidence of pre-existent margi­ nal ulcer in oursmall series. More important, "Vagotomy should be reserved for poor however, is the fact that recurrent ulcer may risk patients with gastrojejunal ulceration occur while physiologic effects of vagotomy after gastroenterostomy in cases of small persist. ulcers or gastrojejunitis, since much better results are obtained by undoing the gas­ "The place of vagotomy in the treatment troenteric anastomosis and the gastric of marginal ulcer after subtotal gastrectomy resection. is substantiated."

"Vagotomy should not be performed for A different opinion was given by George gastric ulceration because ofthe high inci­ Grile, Jr. atthe1952 meetingofthe American dence of an unsuspected malignant process Surgical Association in a paper with the title and because postoperative persisting ul­ "An Analysis of the Vagotomy Controversy." ceration and gastritis and disturbances of He had had experience with 430 cases. motility make the results compare unfavora­ Among his conclusions were the following: bly wfth the excellent results obtained with '"Side effects' which have been attributed to gastric resection for this condition." The vagotomy are in reality complications of an disagreement with Dragstedt in these con­ improperly functioning gastroenterostomy. clusions is evident. "Vagotomy with gastroenterostomy af­ Two years later. Brooks and Moore''^ fords as much protection against recurrent signed off from the vagotomy controversy in ulceration as a three-fourths gastric resec­ a paper with the title "Vagotomy for Duode- tion. More radical gastrectomies result in

42 Early vagotomies lower incidence of recurrent ulceration but R. Dragstedt, who had been invited by one of cause an intolerably high incidence of nutri­ us (C.R.L.). It might conveniently end with tional complications for which there is no the notation that because of agreement with effective treatment. Barney Crile on the points mentioned above, the same one of us in his capacity as Chair­ "Good results were obtained in 90% of man ofthe Program Committee ofthe De­ patients followed for two to five years after troit Academy of Surgery, invited Crile to vagotomy with gastroenterostomy. In 3%, address the monthly meeting of the Acade­ gastric resection for marginal ulcer has been my on December 11,1952, his subject, "An required. Analysis of the Vagotomy Controversy."

"The safety of vagotomy with gastroen­ In 1947, one of us said in an editoriaP" "It terostomy, the absence of side effects when would appear advisable to evaluate the new the gastroenterostomy is constructed prop­ physiologic surgical treatment of ulcers as erly, and the fact that failures are still correc- thoroughly and as rapidly as possible." tible by gastric resection commends vagotomy with gastroenterostomy as the A review ofthe surgical literature, some of standard treatment for complicated duode­ which is given above, initiated this process nal ulcer." which continues to be one of the important areas of experimental and clinical surgery This historical vignette began with an today: a better application ofthe vagotomy account of a medical meeting at the Henry principle in the treatment of peptic ulcer. Ford Hospital when the speaker was Lester

References

1. Dragstedt L R and Owens F M, Jr: Supra­ 7. Alvarez W C: Sixty years of vagotomy: A diaphragmatic section of the vagus nerves in review of some 200 articles. Gastroenterol­ treatment of duodenal ulcer. Proc Soc Exper ogy 10:413, 1948 Biol Med 53:152, 1943 8. Dragstedt L R, Harper P Vjr, Tovee E B, and 2. Dragstedt L R, Palmer W L, and Schafer P W: Woodward E R: Section ofthe vagus nerves to Supra-diaphragmatic section of the vagus the stomach in the treatment of peptic ulcer. nerves in the treatment of duodenal and Ann Surg 126:687, 1947 gastric ulcers. Gastroenterology 3:450, 1944 9. Walters W, Neibling H A, Brandley W F, and 3. Dragstedt L R and Schafer P W: Removal of Small JT: A study ofthe results, both favorable the vagus innervation ofthe stomach in gas­ and unfavorable, of section of the vagus troduodenal ulcer. Surgery 7:742,1945 nerves in the treatment of peptic ulcer. Ann Surg 126:679, 1947 4. Dragstedt L R: Vagotomy for gastroduodenal ulcer. Ann Surg 122:973, 1945 10. Moore F D: Vagus section for ulcer: An 5. ThorntonT FJr, Storer E H, and Dragstedt L R: interim evaluation II. Clinical results. Ann Supra-diaphragmatic section of the vagus Surg 126:664, 1947 nerves.//\MA 130:764, 1946 11. Moore F D, Chapman W p Schultz M F and 6. Dragstedt L R: Section ofthe vagus nerves to Jones C M: Transdiaphragmatic resection of the stomach in the treatment of peptic ulcer. the vagus nerves for peptic ulcer. N Eng j Med Surg Cynec Obstet 83:547, 1946 234:241, 1946

43 Gruenberg and Lam

12. Schoen A M and Griswold R A: The effect of 16. Brooks J R and Moore F D: Vagotomy for vagotomy on human gastric function. Ann duodenal ulcer: A final survey after ten years. Surg 126:655, 1947 New Eng/ Med 249:1089, 1953

13. Discussions on vagotomy at meeting of Amer­ 17. Crile C Jr: An analysis ofthe vagotomy contro­ ican Surgical Association, Hot Springs, Vir­ versy Ann Surg 136:752,1952 ginia, March 1947. Ann Surg 126:699-708, 1947 18. Lam C R: Editorial: Operations on the vagus nerves in the treatment of peptic ulcer. Am j 14. Dragstedt L R, and Woodward E R: Appraisal Surg 74:115, 1947 of vagotomy for peptic ulcer after seven years. JAMA 145:795, 1951

15. Walters W, Belding H H III, and Lillie W I: Physiological and clinical studies of vag- otomized patients: A study of three hundred and thirty-one patients. Arch Surg 62:183, 1951

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