Postgrad Med J: first published as 10.1136/pgmj.26.301.575 on 1 November 1950. Downloaded from November I950 Annotation 575 ANNOTATION with gastrojejunostomy. Furthermore it is the opinion of some surgeons that a coincidental Vagotomy and Pyloroplasty gastro-jejunostomy increases the chance of trouble Few operations have given rise to such varied from post-operative small intestinal ileus-pos- opinions as vagotomy, When it was found that sibly swallowed air may enter and distend the the operation would reduce not only the appetite paretic small bowel faster than the post-operative juice but also the volume of the basal'day and night gastric decompression can deal with it. To add a secretion, high hopes were entertained that this gastrectomy to an adequate vagotomy is to increase might provide a solution to the duodenal ulcer morbidity and mortality, and for 97 out of every problem, particularly for those younger patients ioo who have the combined operation the vago- with duodenal ulcer who had a high acidity and tomy is an unnecessary adjunct. rapidly emptying stomach, the type generally con- The present writer, when commencing to per- sidered least satisfactory for surgery. form vagotomy decided that, as the operation was It was soon found by those surgeons who per- somewhat in the nature of an experiment, he would formed vagotomy alone that in the majority of do pure vagotomies only, because combining it cases, discomfort in the nature of a sensation of with gastro-jejunostomy would confuse the re- epigastric fullness, foul 'sulphurous' belching. sults, for there is no doubt that gastro-jejunostomy abdominal cramps, diarrhoea. etc., might occur, cures duodenal ulcerg even though in a certain and that in a high percentage these symptoms were percentage it gives rise to anastomotic ulceration. still present at the end of a year or more. The H6wever, in those cases of duodenal ulcerationProtected by copyright. cause of these symptoms was basically the com- where there was gross duodenal narrowing, some bination of a lowered acidity with gastric atony accessory operation was obviously required and and delayed emptying. The symptoms in some for these a simple Heineke-Mikulicz pyloroplasty respects resembled those of an achlorhydric was performed. This entails a simple longitudinal stomach partially obstructed by a pyloric incision thiough the scar and pyloric muscle, carcinoma. which is sutured transversely. It is an adequate It was evident to most surgeons that these method of treating stenosis, but has certainly no symptoms were so unpleasant that unless they great reputation for the cure of stenosed duodenal could be overcome the operation must be aban- ulcer and so any longstanding beneficial results doned. Therefore one or other causative factor from the combination of vagotomy with pyloro- had to be eliminated, Administration of large plasty could rightly be attributed to the vagotomy. doses ofacid was impractical and would remove the It did not take long to find that the cases of pure http://pmj.bmj.com/ chief and possibly the sole advantage of the vagotomy had many retention symptoms, whilst operation. Therefore, by some means, gastiic those combined with pyloroplasty were almost emptying had to be improved. symptom-free. Therefore after 9 to i5 months Various parasympatheticomimetic drugs were many of the cases of pure vagotomy were operated used with indifferent success. Dietary regimes of on again, it being suspected that in the worst cases small dry meals with occasional periods of starva- the ulcer had healed and stenosed. However, in on September 26, 2021 by guest. tion or courses of gastric lavage ameliorated but nearly all cases it was found that the ulcer was did not settle the problem. healed, but was not in the least stenosed and there Some surgeons had combined the vagotomy was no evident cause for the prolonged delay in with gastro-jejunostomy or partial gastrectomy, gastric emptying. In view of the success of the and in these cases the post-vagotomy gastric re- pyloroplasty cases, a simple pyloroplasty was per- tention symptoms were slight or absent. The dis- formed on these cases. In the majority of cases re- advantage of gastro-jejunostomy is that we do not lief was rapid, though in cases in which severe re- even yet know if vagotomy is adequate protection tention had been present over a year, it might take against jejunal ulceration. Certainly stomal ulcer up to three months for maximal benefit to appear. occurs at times when the operation is combined The belching of foul flatus disappeared. Postgrad Med J: first published as 10.1136/pgmj.26.301.575 on 1 November 1950. Downloaded from 576 POSTGRADUATE MEDICAL JOURNAL November i 95o As a result of these experiences the writer, in the undamaged sympathetic system, so that there common with many other surgeons, abandoned is either a relative or real pylorospasm. In such a pure vagotomy and now always combines it with case it becomes more evident why division of the pyloroplasty. Occasionally an active anterior ulcer pyloric sphincter should improve gastric emptying, may be encircled by the incision and removed in though in view of the gastric atony which follows order to leave a less scarred duodenum. In rare vagotomy it is still hard to see why pyloroplasty cases the deformity may be so extreme as to make should produce such normal emptying times. The simple pyloroplasty a formidable operation; in emptying time of a barium meal may be reduced such cases a Finney pyloroplasty, or a gastro- by it from I2 or 24 to 3 or 5 hours. jejunostomy may be the wiser procedure. At the I950 Meeting of the Association of It is unlikely that vagotomy will relieve the Surgeons of Great Britain and Ireland, the present average case of gastric ulceration. It is important, writer suggested that pyloroplasty may act not theiefore, not to miss a small coincident gastric merely by removing an obstruction to the gastric ulcer at the time of vagotomy. It is not unlikely chyme, but it may act by equalizing intraduodenal that some of the gastric ulcers now reported as and intragastric pressures. In the normal subject, appearing after vagotomy were present as im- many of the gastric waves are incomplete and in- palpable lesions at the time of the vagotomy, The sufficient in themselves to drive chyme through the pyloroplasty incision gives an added means of ex- pylorus even if the pylorus relaxes in front of the cluding such ulcers. for a finger may be inserted wave. Therefoxe a certain intragastric pressure into the stomach and the lesser curve palpated- must be gradually built up, to equal that in theProtected by copyright. -a far more reliable method of exploration than duodenum, before emptying into the duodenum from outside the stomach. The vaLgotomy should takes place. In the vagotomized stomach even be done before the pyloroplasty and so an ulcer greater difficulty would be experienced. It is found by this means will be discovered after the suggested that the pyloroplasty by throwing the vagotomy has been perforned. Whether the proximal duodenum and stomach into one cavity surgeon should then proceed to gastrectomy or be unseparated by a sphincter, allows the piessures to content with the pyloroplasty is a matter of equalize, so that the gastric chyme may overflow opinion, but at any rate a truer record of the lesion into the duodenum. Once in the duodenum the will be obtained. much more efficient waves of peristalsis relatively Why has pyloroplasty this very fortunate effect? unimpaired by the vagotomy may allow the chyme It certainly does not act merely as a means of over- to be carried on. coming scar contracture because gross stenosis is The true and proven cause of .the improved http://pmj.bmj.com/ not a feature of most of the cases. If gastric emptying must await further observation and re- atony and incomplete gastric peristalsis are the search. Meanwhile there is no doubt that pyloro- cause of the gastric retention it is difficult to see plasty offers a simple and safe method of over- why the pyloroplasty should affect matters, par- coming most of the at present known after-effects ticularly as some observers have claimed that the of vagotomy, and furthermore is a method which pylorus itself was atonic. is unlikely to lead to confusion as to the efficacy on September 26, 2021 by guest. A possible cause of the delayed emptying is that or otherwise of vagotomy in preventing ulcer. the vagotomy diminishes gastric tone, but the tone NORMAN TANNER, F.R.C.S. of the pylorus is maintained or even increased by London.