Selective and highly selective vagotomy with and without

Selective and highly selective vagotomy with and without gastric drainage

Avram M. C o o p e r m a n , M.D

Department of General Surgery

Selective vagotomy and highly selective vagot-omy are opera t ions des igned to i n t e r rup t the vagal nerve supply to the s tomach ei ther totally or partially wi thout d is turb ing vagal innervat ion to the r ema in ing abdominal viscera. T h e y have been d o n e with and without d ra inage proce-dures . 1 - 4

In this brief review both of these operat ions will be descr ibed. T h e theoretical reasons fo r their use a n d the techniques will be discussed, and the results of laboratory studies and clinical exper iences for each type of vagotomy will be summar ized .

T h e t h r ee types of vagotomy are t runcal , se-lective, and highly selective. In the s tandard or t runcal vagotomy, two or m o r e vagal t runks a re divided as they en te r the abdomina l cavity at or below the esophageal h ia tus (Fig. 1). T h e selec-tive vagotomy preserves the hepatic b ranch of the lef t , or an te r ior vagus nerve and the celiac branch of the r ight , or poster ior nerve , achiev-ing total gastric denerva t ion , but leaving he-patic, biliary, and visceral vagal fibers intact (Fig. 2). T h e highly selective vagotomy dener -vates only the proximal s tomach (including the parietal cell mass) leaving antral innervation in-tact via the nerves of Latar je t (Fig. 3).

51

require permission. on December 1, 2021. For personal use only. All other useswww.ccjm.orgDownloaded from

http://www.ccjm.org/

52 Cleveland Clinic Quarter ly

T R U N C A L V A G O T O M Y

Vol. 43, No. 1

Fig. 1. Standard or truncal vagotomy.

Even though truncal vagotomy re-mains the s tandard operat ion in the United States af ter 33 years of clinical trials, there have been theoretical and practical objections to its use since its introduction.3 These objec-tions have been based on the premise that it is illogical and perhaps not necessary to denervate the abdominal viscera just to reduce gastric acidity. Some of these objections are based on the physiologic consequences of gas-tric and extragastric vagal denerva-tion which have been well summa-rized by Ballinger6 and more recently by Johnston.7 T h e effects of com-plete gastric vagotomy (truncal or se-lective) include faster emptying of liquids and slower emptying of solids,8 increased intragastric pres-

sure8 and increased gastric t ransmu-ral pressure , 8 decreased acid secre-tion, and decreased pepsin secre-tion,9 and increased levels of serum gastrin.10 T runca l vagotomy may be accompanied by an increased volume of the resting gallbladder,1 1 , 12 a change in maximal contraction of the gallbladder (slower onset and shor ter durat ion),1 3 a decrease in hepatic bile flow,14 and secretion of bile that is more lithogenic.15 A higher incidence of gallstones is said to follow truncal vagotomy,1 6 but this has not been conf i rmed based on retrospective re-views with their obvious limitations.

T h e effects of vagotomy on pan-creatic secretion are variable.17, 18 A decreased enzyme ou tpu t following vagal stimulation has been repor ted



S u m m e r 1976 Vagotomy with and without gastric dra inage 53

SELECTIVE V A G O T O M Y

Fig. 2. Selective vagotomy.

af te r truncal vagotomy, and pan-creatic secretion itself may be in-creased, decreased, or remain un-c h a n g e d . T h e s e effects are of ques-tionable clinical significance.

T h e effects of vagotomy on the small intestine have included uncoor-dinated motor activity,6 mucosal changes secondary to decreased blood flow,19 decrease in mucosal en-zymes, an increase in bacteria in the small bowel,20 21 and changes in B-12, fat and iron absorption,6 ' 17_2()

which clinically may result in diar-rhea and s teatorrhea.

Despite this large number of ques-tionable side effects, ihe practical points raised against truncal vagot-omy have been twofold. (1) A 15% to

30% incidence of incomplete nerve resection as proven by Hol lander testing. (2) A 20% to 60% incidence of d ia r rhea following truncal vagot-omy.22 ' 23

Selective vagotomy

What does selective vagotomy of-fer? When First described in 1948, it was hoped that selective vagotomy would reduce the incidence of recur-rent ulcer and incomplete vagotomy and d ia r rhea . T h e technique has been well described by Griffith2 4 who stated that the operation begins at the gastric cardia (not at the hiatus) where all vagal fibers join. Af te r identifying and preserving both the hepatic branch of the left vagus nerve



54 Cleveland Clinic Quar te r ly Vol. 43, No. 1

P A R I E T A L CELL V A G O T O M Y

Fig. 3. Par ie ta l cell o r h igh ly select ive v a g o t o m y .

and the celiac branch of the right vagus nerve, both t runks a re t ran-sected beneath this point .

Does selective vagotomy allow fo r m o r e complete vagotomies? Compa-rable repor ts of postoperat ive ulcer recur rences and Hol lander tests in series of patients who u n d e r w e n t se-lective and t runcal vagotomy have been publ ished. In nearly all repor t s positive early Hol lander tests were f o u n d less f requent ly a f t e r selective than a f t e r t runcal vagotomy. In nearly every r epo r t results were bet-ter a f t e r selective than a f t e r t runcal vagotomy.2 5 - 3 2 T w o repor t s showed that a very satisfactory result could be obtained with e i ther t runcal or selec-tive vagotomy but even in one of these repor t s , a f t e r a t ra in ing per iod

of 11 selective vagotomies only two of the next 150 had early positive Hol-lander tests (1.5%), whereas a 6% fig-ure of positive Hol lander tests follow-ing t runcal vagotomy rema ined un-changed .

What a re the reasons for this? Could the reasons be related to tech-nique? Could many of these repor ts have been published by inexperi-enced vagotomists? How impor tan t is inexper ience as a factor? In a delight-ful study by Johns ton and Goligher,3 3

postoperat ive insulin tests were com-pared a f t e r vagotomies were d o n e by consul tant surgeons and registrars . Of 346 vagotomies d o n e by consult-ants, 18% were incomplete ; of 312 vagotomies done by registrars , 12% were incomplete . T h e ability to per-



S u m m e r 1976 Vagotomy with a n d wi thout gastric d ra inage 55

f o r m comple te vagotomy varied f r o m surgeon to su rgeon regardless of his status. O t h e r reasons fo r the h igher incidence of incomplete vagotomy following t runcal division are based on anatomic and physiologic factors .

1. Sawyers a n d Scott34 believe that the ex t ra time and e f f o r t r equ i red for selective vagotomy account for m o r e comple te division of vagal f ibers .

2. Grif f i th 2 4 believes that because the dissection begins lower on the esophagus where fewer f ibers are missed, the results a re be t ter .

3. Exper imenta l a n d indirect clini-cal evidence suggests that selective vagotomy, by leaving pyloroduo-denal innervat ion intact, allows release of a humora l inhibi tor of gas-tric secretion.3 5 Lower levels of s e rum gastrin a f t e r selective vagotomy ra the r than a f te r t runcal vagotomy have been expla ined by this innerva-tion which may allow release of gas-trin inhibi tors .

T h e second p re sumed advan tage of selective vagotomy is that d i a r rhea occurs less f requent ly than a f t e r t runcal vagotomy. Dia r rhea a f t e r t runcal vagotomy without an accom-pany ing d ra inage p r o c e d u r e was noted in 25 of 61 cases r epo r t ed by Drags ted t et al36 in 1947. In the now f a m o u s prospective Leeds-York Study3 7 in which 360 males u n d e r -went elective duodena l ulcer surgery by one of th ree opera t ions , one of the few significant d i f ferences observed was a lower incidence of d i a r rhea a f t e r subtotal gastric resection than a f te r vagotomy opera t ions .

T h e r e p o r t e d incidence of diar-rhea in similar series of pat ients who u n d e r w e n t t runcal and selective va-gotomy with similar d ra inage proce-dures has been summar ized . In these r e p o r t e d series the d ra inage proce-d u r e was identical f o r t runcal vagot-

omy a n d selective vagotomy. T h e in-cidence of d i a r rhea a f t e r t runcal va-gotomy a n d dra inage in 1,230 pa-tients was 24.6%, but in 830 patients u n d e r g o i n g selective vagotomy it was 12.3%. In all studies (14 were cited), the incidence of d ia r rhea was less a f t e r selective than a f t e r t runcal va-gotomy, bu t the 12.3% incidence of d i a r rhea following selective vagot-omy may still be unacceptably h igh . Al though d i a r rhea is t roublesome in less than 5% of patients, the fact that pa ramete r s d o not exist p reopera -tively f o r predic t ing and ident i fying susceptible pat ients may make some physicians wary of these opera t ions . W h e t h e r this high incidence re-por ted f r o m many E u ro p ean coun-tries reflects a grea ter incidence, a m o r e objective and t h o r o u g h assess-m e n t of postvagotomy func t ion , or d i f fe rences in patient popula t ion , cannot be stated with certainty, al-t hough the detail and m a n n e r of fol-low-up in some repor t s seem more objective and t h o r o u g h than that in similar studies f r o m the United States.

Is an accompanying dra inage pro-cedure necessary with selective va-gotomy? Opin ions vary. Wastell et al,1 DiMiguel,2 and Clarke et al3 ob-served that m o r e than 50% of pa-tients who had selective vagotomy without d ra inage had gastric stasis necessitating a d ra inage opera t ion in many . O t h e r large series4 showed that in nonobs t ruc ted ulcer patients selective vagotomy without dra inage could be accomplished with a stasis ra te of 11%.

Highly selective vagotomy

T h e second and newer opera t ion to be summar ized is the highly selec-tive vagotomy.3 8 It has also been called parietal cell vagotomy,3 9 super-



56 Cleveland Clinic Quar te r ly Vol. 43, N o . 3

selective vagotomy, part ial gastric va-gotomy,4 0 ultraselective vagotomy,4 1

and proximal gastric vagotomy.4 2

This opera t ion is des igned to de-nervate the parietal cell mass leaving the antra l nerves of Latar je t intact. Leaving the vagus intact to the an-t r u m seems cont rary to popu la r teaching, since the increased gastric p H has been t hough t to release gas-tr in and cause hyperacidi ty. This is more theoretical than observed.4 3

Parietal cell vagotomy was first p roposed by Gri f f i th a n d Harkins4 0

in 1957. In their p a p e r on partial gas-tric vagotomy, the p r o c e d u r e was p e r f o r m e d in 10 dogs , and satisfac-tory gastric empty ing and secretory studies were observed. T h e investiga-tors concluded that clinical applica-tions seemed feasible. More recently the d i f fe rences between t runcal , se-lective, and highly selective vagotomy on gastric pressures a n d empty ing were s tudied by Wilbur and Kelly.8

Highly selective vagotomy preserved gastric empty ing and motility bet ter than t runcal vagotomy or selective vagotomy. T h e only funct ional ab-normali ty a f t e r highly selective vagot-omy was quicker empty ing of liquids f r o m the s tomach than a f t e r t runcal o r selective vagotomy. T h e reasons fo r this may be that with proximal gastric denerva t ion the f u n d u s of the stomach does not relax to accommo-date ingesta. Control of empty ing of liquids is regula ted by the f u n d u s . Gastric t r ansmura l pressure increases rapidly and the stomach empties liq-uids into the d u o d e n u m m o r e rap-idly. Since empty ing of solids is regu-lated by the a n t r u m 9 this is not al-te red by highly selective vagotomy.

T h e techniques of this opera t ion have been described by several sur-geons.38 , 4 4 , 4 5 At opera t ion the nerves

of Latar je t must be ident i f ied, and all s t ruc tures between these nerves and the lesser curva ture a re d iv ided . W h e n one does this ope ra t ion ini-tially the re is concern that some im-po r t an t gastric fibers may be missed, a l though this has not been b o r n e out in r epor t s . It is impor tan t that techni-cal details be meticulously fol lowed; unsat isfactory results may be due to technical fai lures. T h e very benign postopera t ive course exper ienced by these pat ients has been observed by many .

W h o is eligible for parietal cell va-gotomy? In 197 037, 46 it was suggested that thin patients with nonobs t ruc t -ing, noncompl ica ted d u o d e n a l ulcers would be an ideal g r o u p , bu t in 197 338, 47 these indications were ex-t ended to some patients with per fo-ra t ed , obs t ructed , and h e m o r r h a g i c ulcers. Some patients with gastric ul-cers have also been inc luded. 4 8 T o date m o r e than 5,000 highly selective vagotomies have been done . 4 9 In evaluat ing this opera t ion we want to ask of it what should be asked of all ulcer opera t ions . As summar ized by Priestley,50 (1) the pat ient should sur-vive the opera t ion; (2) the ulcer should heal if it has not been re-moved; (3) r ecu r ren t ulcers should be p reven ted ; and (4) the pat ient should remain f r ee of any unp leasan t gas-trointest inal symptoms.

Is this a safe opera t ion? Of the 5,539 opera t ions summar ized by J o h n s t o n , the operative mortali ty has been 0.37%.49

What is the incidence of r ecu r r en t ulcer? O n e h u n d r e d five patients have been followed f o r 2 o r m o r e years and 206 for 4 or m o r e years. D u r i n g this per iod th ree pat ients re-qu i red a gastric d ra inage p r o c e d u r e and t h r ee patients had suspected (but



S u m m e r 1976 Vagotomy with a n d wi thout gastric d ra inage 57

not proven) d u o d e n a l ulcers, making a total of 1.3% f o r suspected o r p roven recurrence . 5 1 In the most re-cent publication, J o h n s t o n et al°2

noted a r ecu r rence rate of 1.0% in 100 patients fol lowed 5 or m o r e years.

What about gastrointest inal dys-funct ion? T h e incidence of undesi ra-ble side effects a f t e r subtotal gastric resection, vagotomy a n d ant rec tomy, and vagotomy and gastroenteros-tomy has been r e p o r t e d by Goligher et al.37 When the side effects a re com-pa red with those a f t e r parietal cell vagotomy (done by the same sur-geons) d ia r rhea , bile vomit ing, and d u m p i n g each occur less o f ten . 7 A significantly h igher incidence of good or excellent results follows this opera t ion when it is compared to o the r gastric opera t ions fo r duodena l ulcer.7 , 53

What about the increased inci-dence of d ia r rhea? In a study re-por ted by J o h n s t o n et al22 the results of highly selective vagotomy, truncal vagotomy, and selective vagotomy were evaluated with control patients. T h e incidence of d i a r rhea was signif-icantly less a f t e r highly selective va-gotomy. T h e incidence of d ia r rhea was 24% af te r t runca l vagotomy and pyloroplasty (6% severe), 18% af te r selective vagotomy a n d pyloroplasty (2% severe), and 2% a f t e r highly se-lective vagotomy. In the control g r o u p of 50 patients who had in-guinal h e r n i o r r h a p h y or saphenous vein ligation, 4% had episodic diar-rhea . T h e incidence of d i a r rhea was increased in all g roups by giving hy-per tonic glucose. Th i s was d u e to in-creased gastric empty ing and transit d u e to hyper tonic glucose.

Is d u m p i n g seen less o f t en a f te r highly selective vagotomy? T h e same patients a n d controls were quer ied

r ega rd ing d u m p i n g , de f ined as an early pos tprandia l vasomotor reac-tion.5 3 T h e incidence at 1 year was 20% af te r t runcal vagotomy and pylo-roplasty, 34% af te r selective vagot-omy and pyloroplasty, and 6% a f t e r highly selective vagotomy; and at 2 to 4 years was 11% vagotomy and dra in-age, 25% selective vagotomy and d ra inage , and 6% highly selective va-gotomy. T h e incidence in control pa-tients was 4%. T h e s e f igures are not wholly comparab le , since in the first two opera t ions the pyloric canal was d i s rup t ed . Again , a test meal showed increased incidence of d u m p i n g in all g roups , but it was highest in the se-lective vagotomy g r o u p . O the r s have observed this and relate it to the release of vagally controlled vasoac-tive substances with selective vagot-omy that a re absent a f t e r t runcal va-gotomy.5 4 , 55

What abou t secretory studies? T h e mean values fo r basal and maximal acid o u t p u t at 1 week, 2 to 3 months , and 12 to 24 mon ths a f t e r highly se-lective vagotomy have been studied.5 6

T h e basal acid o u t p u t was decreased 92% in 1 week, 86% in 2 to 3 weeks; acid o u t p u t between 3 mon ths a n d 1 year was statistically significant. Simi-larly, a fall, then significant rise in maximal acid o u t p u t has been ob-served. T h e s e au thors noted similar changes following t runcal vagotomy and selective vagotomy and the sig-nificance of these changes is not known. Even fo r patients who are hypersecre tors the 5-year fol low-up of 100 pat ients has shown no h igher incidence of ulcers a f te r highly selec-tive vagotomy.5 2

T h e last question about parietal cell vagotomy opera t ion is whe the r a d ra inage p r o c e d u r e is necessary. Sci-ence and surgery agree , since stasis



58 Cleveland Clinic Quar ter ly Vol. 43, N o . 3

has occur red in less than 270 of the r epo r t ed cases.49 T o f u r t h e r prove this point , Clarke et al3 and Wastell et al1 s tudied two g roups of patients who u n d e r w e n t highly selective va-gotomy with and without pyloro-plasty. Secretory studies a f te r insulin and pentagastrin were similar as were changes in se rum gastrin. T h e gastrin response to a protein meal was two times as g rea t a f t e r highly selective vagotomy without dra inage. 5 7 Motil-ity and empty ing seemed bet ter when pyloroplasty was omit ted.

Summary

T w o opera t ions , selective gastric vagotomy (total gastric denervat ion) and highly selective vagotomy (par-tial gastric denervat ion) have been re-viewed.

T h e advantages of selective vagot-omy over t runcal vagotomy are due to bet ter results with postoperat ive Hol lander tests and less d ia r rhea . T h e r e is a h ighe r incidence of d u m p -ing; a d ra inage p r o c e d u r e may possi-bly be omi t ted if obstruct ion is ab-sent . T h e pat ients should be followed closely because gastric stasis requir-ing a d ra inage p r o c e d u r e may de-velop.

A newer opera t ion , highly selective vagotomy (parietal cell vagotomy) has also been reviewed. Its theoretical ad-vantages have been reviewed and available clinical trials summar ized . Af te r this opera t ion the results of se-cretory studies are satisfactory and there is a very low incidence of diar-rhea , d u m p i n g , and o the r unpleas-ant gastrointestinal complications when c o m p a r e d to o the r ulcer opera-tions. T h e longest fol low-up, how-ever, has been only 4 years.

Will this become the s t andard ulcer opera t ion o r will it fall by the way-

side? T h e answer is no t yet known, bu t all gastric surgeons should heed Sir Og i l iv ie^ 5 8 "Every opera t ion for ulcer appea r s to be a success until it is f o u n d ou t . " T i m e will tell.

References

1. Was te l l C , Co l in J F , M a c N a u g h t o n J I , e t a l : Se lec t ive p r o x i m a l v a g o t o m y wi th a n d w i t h o u t p y l o r o p l a s t y . B r M e d J 1: 28 , 1972.

2 . D e M i g u e l J : E f f e c t o d e la v a g o t o m i a selec-t iva sin d r e n a j e s o b r e el v a c i a m i e n t o de l e s t o m a g o . C i r E s p a n o l a 24: 121-126 , 1970.

3 . C l a r k e R J , A l l a n R N , A l e x a n d e r - W i l l i a m s J : T h e e f f e c t o f p r e s e r v i n g a n t r a l i n n e r v a -t i o n a n d o f a p y l o r o p l a s t y o n ga s t r i c e m p -t y i n g a f t e r v a g o t o m y in m a n . G u t 14: 3 0 0 -307, 1973.

4 . B u r g e H , M a c L e a n C , S t e d e f o r d R , e t a l : Se lec t ive v a g o t o m y w i t h o u t d r a i n a g e ; a n i n t e r i m r e p o r t . B r M e d J 3: 6 9 0 - 6 9 3 , 1969.

5 . D r a g s t e d t L R , O w e n s F M J r : S u p r a - d i a -p h r a g m a t i c s ec t i on of t h e v a g u s n e r v e s in t h e t r e a t m e n t o f d u o d e n a l u l c e r . P r o c Soc E x p Biol M e d 53: 152-154 , 1943.

6 . B a l l i n g e r W F I I : T h e e x t r a g a s t r i c e f f e c t s o f v a g o t o m y . S u r g Clin N o r t h A m 46: 4 5 5 -462 , 1966.

7 . J o h n s t o n D : A n e w l o o k a t v a g o t o m y . S u r g A n n u 6: 125-160 , 1974.

8 . W i l b u r B G , Kel ly K A : E f f e c t o f p r o x i m a l g a s t r i c , c o m p l e t e gas t r i c , a n d t r u n c a l va-g o t o m y o n c a n i n e ga s t r i c e l ec t r i c ac t iv i ty , mo t i l i t y a n d e m p t y i n g . A n n S u r g 178: 2 9 5 -303, 1973.

9 . S a m l o f f I M , Sec r i s t D M , P a s s a r o E J r : Se-r u m g r o u p I p e p s i n o g e n levels a n d t h e i r r e l a t i o n t o ga s t r i c ac id s e c r e t i o n in p a t i e n t s wi th a n d w i t h o u t r e c u r r e n t u l c e r . G a s t r o -e n t e r o l o g y 70: 3 0 9 - 3 1 3 , 1976.

10. H a n s k y J , K o r m a n M G : I m m u n o a s s a y s t u d i e s in p e p t i c u l c e r . C l in G a s t r o e n t e r o l 2: 2 7 5 - 2 9 1 , 1973.

11. P a r k i n G J S , S m i t h R B , J o h n s t o n D : Gal l -b l a d d e r v o l u m e a n d c o n t r a c t i l i t y a f t e r t r u n c a l , se lec t ive a n d h i g h l y se lec t ive (pa -r ie ta l -ce l l ) v a g o t o m y in m a n . A n n S u r g 178: 5 8 1 - 5 8 5 , 1973.

12. J o h n s o n F E , B o y d e n E A : T h e e f f e c t o f d o u b l e v a g o t o m y o n t h e m o t o r act ivi ty o f t h e h u m a n gall b l a d d e r . S u r g e r y 32 : 591 — 601, 1952.

13. G l a n v i l l e J N , D u t h i e H L : C o n t r a c t i o n o f t h e gal l b l a d d e r b e f o r e a n d a f t e r to ta l a b -



S u m m e r 1976 Vagotomy with a n d without gastric d ra inage 59

d o m i n a l v a g o t o m y . Cl in R a d i o l 15: 3 5 0 -354, 1964.

14. F l e t c h e r D M , C l a r k C,G: C h a n g e s in c a n i n e b i l e - f l ow a n d c o m p o s i t i o n a f t e r v a g o t o m y . B r J S u r g 56: 103-106 , 1969.

15. C o w i e A G A , C l a r k C G : T h e l i t h o g e n i c e f -f ec t o f v a g o t o m y . B r J S u r g 59: 3 6 5 - 3 6 7 , 1972.

16. T o m p k i n s R K , K r a f t A R , Z i m m e r m a n E, e t a l : Cl in ica l a n d b i o c h e m i c a l e v i d e n c e o f i n c r e a s e d g a l l s t o n e f o r m a t i o n a f t e r c o m -p l e t e v a g o t o m y . S u r g e r y 71: 196-200 , 1972.

17. D r e i l i n g D A , D r u c k e r m a n L J , H o l l a n d e r F: T h e e f f e c t o f c o m p l e t e v a g i s e c t i o n a n d vaga l s t i m u l a t i o n o n p a n c r e a t i c s e c r e t i o n in m a n . G a s t r o e n t e r o l o g y 20: 5 7 8 - 5 8 6 , 1972.

18. T h a m b u g a l a R L , B a r o n J H : P a n c r e a t i c se-c r e t i o n a f t e r se lec t ive a n d t r u n c a l v a g o t -o m y in t h e d o g . B r J S u r g 58: 8 3 9 - 8 4 4 , 1971.

19. B a l l i n g e r W F I I , I i d a J , P a d u l a R T , e t a l : B a c t e r i a l i n f l a m m a t i o n a n d d e n e r v a t i o n a t r o p h y of t h e sma l l i n t e s t i n e . S u r g e r y 57: 5 3 5 - 5 4 1 , 1 9 6 5 .

20 . G r e e n l e e H B , Vivit R , P a e z L , e t a l : B a c t e -r ial f l o r a o f t h e j e j u n u m f o l l o w i n g p e p t i c u l c e r s u r g e r y . A r c h S u r g 102: 2 6 0 - 2 6 5 , 1971.

21 . B r o w n i n g G G , B u c h a n K A , M a c k a y C : S m a l l - b o w e l f l o r a a n d b o w e l h a b i t s t u d i e d at i n t e r v a l s f o l l o w i n g v a g o t o m y a n d d r a i n -a g e . B r J S u r g 59: 9 0 8 - 9 0 9 , 1972.

22 . J o h n s t o n D , H u m p h r e y C S , W a l k e r B E , e t a l : V a g o t o m y w i t h o u t d i a r r h o e a . B r M e d J 3: 7 8 8 - 7 9 0 , 1972.

23 . H a r k i n s H N , S t a v n e y LS , G r i f f i t h C A , et a l : Se l ec t ive g a s t r i c v a g o t o m y . A n n S u r g 158: 4 4 8 - 4 6 0 , 1963.

24 . G r i f f i t h C A : Se lec t ive ga s t r i c v a g o t o m y . S u r g Cl in N o r t h A m 46: 3 6 7 - 3 7 7 , 1966.

25 . Ross B , Kay A W : T h e i n s u l i n t es t a f t e r v a g o t o m y . G a s t r o e n t e r o l o g y 46: 3 7 9 - 3 8 6 , 1964.

26 . H e d e n s t e d t S, L u n d q u i s t G : Se l ec t ive gas-t r ic v a g o t o m y v e r s u s to ta l a b d o m i n a l va-g o t o m y . A c t a C h i r S c a n d 131: 4 4 8 - 4 5 9 , 1966.

27 . A m d r u p E , C l e m m e s e n T , A n d r e a s s e n J : Se l ec t ive ga s t r i c v a g o t o m y t e c h n i c a n d p r i -m a r y r e s u l t s . A m J D i g Dis 12: 3 5 1 - 3 5 5 , 1967.

28 . S c h e i n i n T M , I n b e r g M : T h e a n a t o m i c a l bas is o f se lec t ive v a g o t o m y . A n n C h i r G y n a e c F e n n 55 : 164-167 , 1966.

29. K e n n e d y T , C o n n e l l A M : Se lec t ive o r t r u n c a l v a g o t o m y ? A d o u b l e - b l i n d r a n -d o m i s e d c o n t r o l l e d t r i a l . L a n c e t 1: 8 9 9 -901, 1969.

30. S a w y e r s J L , S c o t t H W J r , E d w a r d s W H , e t al: C o m p a r a t i v e s t u d i e s o f t h e clinical e f -fec t s o f t r u n c a l a n d se lec t ive ga s t r i c v a g o t -o m y . A m J S u r g 115: 165-172 , 1968.

31. M a s o n M C , Gi les G R , G r a h a m N G , et a l : A n e a r l y a s s e s s m e n t of se lec t ive a n d to ta l v a g o t o m y . B r J S u r g 55: 6 7 7 - 6 8 0 , 1968.

32. K r o n b o r g O , M a l m s t r o m J , C h r i s t i a n s e n P M : A c o m p a r i s o n b e t w e e n t h e r e su l t s o f t r u n c a l a n d se lec t ive v a g o t o m y in p a t i e n t s wi th d u o d e n a l u l c e r . S c a n d J G a s t r o e n -t e ro l 5: 5 1 9 - 5 2 4 , 1970.

33. J o h n s t o n D , G o l i g h e r J C : T h e i n f l u e n c e o f t h e i n d i v i d u a l s u r g e o n a n d o f t h e t y p e o f v a g o t o m y u p o n t h e i n su l i n t es t a f t e r v a g o t -o m y . G u t 12: 9 6 3 - 9 6 7 , 1971.

34. S a w y e r s J L , S c o t t H W J r : Se lec t ive gas t r i c v a g o t o m y wi th a n t r e c t o m y o r p y l o r o -p l a s ty . A n n S u r g 174: 5 4 1 - 5 4 7 , 1971.

35. Kelly K A , N y h u s L M , H a r k i n s H N : T h e vaga l n e r v e a n d t h e i n t e r n a l p h a s e of gas-t r ic s e c r e t i o n . G a s t r o e n t e r o l o g y 46: 163-166, 1964.

36. D r a g s t e d t L R , H a r p e r P V J r , T o v e e E B , et al: S e c t i o n o f t h e v a g u s n e r v e s t o t h e s t o m -a c h in t h e t r e a t m e n t o f p e p t i c u l c e r ; c o m -p l i c a t i o n s a n d e n d r e s u l t s a f t e r f o u r y e a r s . A n n S u r g 126: 6 8 7 - 7 0 8 , 1947.

37. G o l i g h e r J C , P u l v e r t a f t C N , d e D o m b a l F T , e t a l : Five- to e i g h t - y e a r r e s u l t s o f L e e d s / Y o r k c o n t r o l l e d t r ia l o f e lec t ive s u r -g e r y f o r d u o d e n a l u l c e r . B r M e d J 2: 781 — 787, 1968.

38. H a l l e n b e c k G A : H i g h l y se lec t ive p r o x i m a l ga s t r i c v a g o t o m y . H o s p P r a c t 8: 96, 1973.

39. A m d r u p E , J e n s e n H E : Se lec t ive vago t -o m y o f t h e p a r i e t a l cell m a s s p r e s e r v i n g i n n e r v a t i o n o f t h e u n d r a i n e d a n t r u m , a p r e l i m i n a r y r e p o r t o f r e s u l t s in p a t i e n t s wi th d u o d e n a l u l c e r . G a s t r o e n t e r o l o g y 59: 5 2 2 - 5 2 7 , 1970.

40. G r i f f i t h C A , H a r k i n s H N : Pa r t i a l gas t r i c v a g o t o m y ; a n e x p e r i m e n t a l s t u d y . G a s t r o -e n t e r o l o g y 32: 9 6 - 1 0 2 , 1957.

41. G r a s s i G , O r e c c h i a C , S b u e l z B , e t al: Ea r ly r e s u l t s o f t h e t r e a t m e n t o f d u o d e n a l u l c e r by u l t r a s e l e c t i v e v a g o t o m y w i t h o u t d r a i n -a g e . S u r g G y n e c o l O b s t e t 136: 726 -728 , 1973.

42. K e n n e d y T . J o h n s t o n G W , M a c r a e K D , e t a l : P r o x i m a l g a s t r i c v a g o t o m y — i n t e r i m r e -su l t s o f a r a n d o m i z e d c o n t r o l l e d t r ia l . B r



60 Cleveland Clinic Quar ter ly Vol. 43, No . 3

M e d J 2: 3 0 1 - 3 0 3 , 1975. 43 . J o h n s t o n D , H u m p h r e y C S , S m i t h R B , et

al: S h o u l d t h e gas t r i c a n t r u m b e vagal ly d e n e r v a t e d i f it is well d r a i n e d a n d in t h e ac id s t r e a m ? B r J S u r g 58: 7 2 5 - 7 3 1 , 1971.

44 . G o l i g h e r J C : A t e c h n i q u e f o r h i g h l y selec-t ive ( p a r i e t a l cell o r p r o x i m a l gas t r i c ) va-g o t o m y f o r d u o d e n a l u l c e r . B r J S u r g 61: 3 3 7 - 3 4 5 , 1974.

45 . C o o p e r m a n A : H i g h l y se l ec t ive v a g o t o m y . S u r g Cl in N o r t h A m , 1976. I n p r e s s .

46 . J o h n s t o n D , W i l k i n s o n A R : H i g h l y selec-t ive v a g o t o m y w i t h o u t a d r a i n a g e p r o c e -d u r e in t h e t r e a t m e n t o f d u o d e n a l u l c e r . B r J S u r g 57: 2 8 9 - 2 9 6 , 1970.

47 . J o h n s t o n D , L y n d o n P J , S m i t h R B , et a l : H i g h l y se lec t ive v a g o t o m y w i t h o u t a d r a i n -a g e p r o c e d u r e in t h e t r e a t m e n t o f h a e -m o r r h a g e , p e r f o r a t i o n , a n d p y l o r i c s t e n o -sis d u e t o p e p t i c u l c e r . B r J S u r g 60: 7 9 0 -797, 1973.

48. J o h n s t o n D , H u m p h r e y C S , S m i t h R B , et al: T r e a t m e n t o f ga s t r i c u l c e r by h i g h l y se lec t ive v a g o t o m y w i t h o u t a d r a i n a g e p r o -c e d u r e ; a n i n t e r i m r e p o r t . B r J S u r g 59: 787, 1972.

49. J o h n s t o n D: O p e r a t i v e m o r t a l i t y a n d pos t -o p e r a t i v e m o r b i d i t y of h i g h l y se lec t ive va-g o t o m y . B r J S u r g 62: 160, 1975.

50. P r i e s t l ey J T : T h o u g h t s r e g a r d i n g t h e pa -t i e n t w i th c h r o n i c d u o d e n a l u l c e r . S u r g Cl in N o r t h A m 4 7 : 8 4 1 - 8 5 0 , 1967.

51. J o h n s t o n D , W i l k i n s o n A R , H u m p h r e y C S , e t a l : S e r i a l s t u d i e s o f g a s t r i c s e c r e t i o n

in p a t i e n t s a f t e r h i g h l y se lec t ive ( p a r i e t a l ce l l ) v a g o t o m y w i t h o u t a d r a i n a g e p r o c e -d u r e f o r d u o d e n a l u l c e r . I . E f f e c t o f h i g h l y se l ec t ive v a g o t o m y o n ba sa l a n d p e n t a g a s t r i n - s t i m u l a t e d m a x i m a l a c i d o u t -p u t . G a s t r o e n t e r o l o g y 64: 1 - 1 1 , 1973.

52. J o h n s t o n D, P i c k f o r d I R , W a l k e r B E , e t a l : H i g h l y se lec t ive v a g o t o m y f o r d u o d e n a l u l c e r : D o h y p e r s e c r e t o r s n e e d a n t r e c -t o m y ? B r M e d J 1: 7 1 6 - 7 1 8 , 1975.

53 . H u m p h r e y CS, J o h n s t o n D , W a l k e r B E , e t a l : I n c i d e n c e of d u m p i n g a f t e r t r u n c a l a n d se l ec t ive v a g o t o m y wi th p y l o r o p l a s t y a n d h i g h l y se lec t ive v a g o t o m y w i t h o u t d r a i n -a g e p r o c e d u r e . B r M e d J 3: 7 8 5 - 7 8 8 , 1972.

54. T o v e y F I : A c o m p a r i s o n o f p o l y a g a s t r e c -t o m y , t o t a l a n d se lec t ive v a g o t o m y , a n d o f p y l o r o p l a s t y a n d g a s t r o j e j u n o s t o m y . B r J S u r g 56: 2 8 1 - 2 8 6 , 1969.

55 . K r a f t R O , F r y W J , W i l h e l m K G , e t a l : S e l e c t i v e gas t r i c v a g o t o m y ; a c r i t ica l r e a p -p r a i s a l . A r c h S u r g 95: 6 2 5 - 6 3 0 , 1967.

56. J e p s o n K , L a r i J , H u m p h r e y C S , e t a l : A c o m p a r i s o n o f t h e e f f e c t s o f t r u n c a l , se lec-t ive , a n d h i g h l y se lec t ive v a g o t o m y o n m a x i m a l ac id o u t p u t in r e s p o n s e t o p e n t a -g a s t r i n . A n n S u r g 178: 7 6 9 - 7 7 2 , 1973.

57. K o r m a n M G , H a n s k y J , C o u p l a n d G A E , e t a l : G a s t r i n s t u d i e s a f t e r p a r i e t a l cell va-g o t o m y ; is d r a i n a g e n e c e s s a r y ? D i g e s t i o n 8 : 1 - 7 , 1973.

58 . M a i n g o t R : A b d o m i n a l O p e r a t i o n s , v. 1, e d 5. N e w Y o r k , A p p l e t o n - C e n t u r y -C r o f t s , 1969, p 466.



Documents

Selective and highly selective vagotomy with and without