Anterior seromyotomy with posterior truncal vagotomy in uncomplicated chronic duodenal ulcer.
A Supe, R Bhalla, SV Pandya, NH Doctor, VN Bapat
Department of Surgery, Seth GS Medical College, Parel, Bombay, India., India
Department of Surgery, Seth GS Medical College, Parel, Bombay, India.
Thirty cases of uncomplicated duodenal ulcer treated by anterior superficial lesser curvature seromyotomy and posterior truncal vagotomy were studied to evaluate the efficacy of this procedure. There was completeness of vagotomy in all the cases as shown by endoscopic Congo Red test. Twenty-seven cases were asymptomatic at 1-48 months (Mean 22.3) follow up, while 3 patients had controllable side effects such as dumping and diarrhoea. There was no mortality. This procedure is safe, effective and is a favourable alternative to highly selective vagotomy.
|How to cite this article:|
Supe A, Bhalla R, Pandya S V, Doctor N H, Bapat V N. Anterior seromyotomy with posterior truncal vagotomy in uncomplicated chronic duodenal ulcer. J Postgrad Med 1995;41:61-3
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Supe A, Bhalla R, Pandya S V, Doctor N H, Bapat V N. Anterior seromyotomy with posterior truncal vagotomy in uncomplicated chronic duodenal ulcer. J Postgrad Med [serial online] 1995 [cited 2019 Oct 13 ];41:61-3
Available from: http://www.jpgmonline.com/text.asp?1995/41/3/61/492
The advent of potent medical therapy, resulted in the reduction of elective duodenal ulcer surgery, Surgical treatment is thus preferred by patients who become weary of continuous medication in the long term, especially as the majority of them are young to middle aged active individuals. In addition, one has to consider the cost of treatment, which over a 10 to 15 year period, becomes substantial. Highly Selective Vagotomy (HSV) gained acceptance in the treatment of acid peptic disease as it achieves cure or control of the peptic ulcer with preservation of the innervated antrum and pylorus and has low incidence of the undesirable side effects of other forms of gastric surgery, Despite these advantages, the operation does have some disadvantages; it can be tedious and time consuming to perform damage to nerves of Latarjet might produce gastric stasis and there is a small risk of ischaemic necrosis of lesser curvature which, when it occurs can be fatal.
Lesser curve superficial seromyotomy was designed in 1979 to increase the speed and ease of vagotomy of the parietal cell mass and to avoid any risk of damage to the nerves of Latarjet. The procedure was modified by Walker and Taylor in 1982. To reduce the speed and make it more easy anterior seromyotomy with posterior truncal vagotomy (ASMPTV) was carried out The operation has been used by a few workers and was found to be safe, effective and results are comparable to HSV,,, but the experience is still limited. The present prospective study was carried out to evaluate the effectiveness of anterior seromyotomy with posterior truncal vagotomy (ASMPTV) in the treatment of chronic duodenal ulcers.
The procedure was carried out on 30 patients (29 males, 1 female; Age 2052 yrs, mean 34.2) with proven chronic duodenal ulcer who had history of ulcer pain in all the cases without any complications such as haematemesis, malena or perforation. The diagnosis was confirmed by upper GI endoscopy (Olympus XQ 20) in all. The procedure was carried out electively and only in uncomplicated cases. Gastroduodenal outlet obstruction was ruled out by saline load test in all the patients and by barium meal examination in seven patients. All patients had a full trial with H2 receptor antagonist before surgery was planned.
The operation was carried out as described by Taylor et al. The abdomen was opened by an upper midline incision. After confirmation of the presence of duodenal ulcer, both anterior and posterior vagal trunks were identified and placed in slings. Posterior truncal vagotomy and division of the branches of posterior vagus to the fundus (the criminal nerves of Grassi) was carried out. The anterior surface of the stomach was stretched and a 0.5 to 1 cm incision made parallel to the lesser curvature, dividing the serosa and muscle from 7 cm proximal to the pylorus, up across the gastroesophageal junction, and laterally towards the fundus. Five to six superficial prominent vessels encountered in the line of incision were ligated and divided. An overlap repair of seromyotomy was carried out by a catgut stitch taken from the seromuscular layer to the left of the myotomy in an oblique fashion. Abdomen was closed in layers and Ryle's tube was removed after 24 hours when oral feeds were started. All patients were operated through similar technique by senior members as well as junior registrars of the unit. Per-operative antibiotic prophylaxis was followed in all the cases. The operating time and blood loss during surgery and postoperative wound infection was noted.
The completeness of vagal denervation was assessed by endoscopic Congo Red test after 4 weeks. Postoperatively patients were regularly followed up for complications and the efficacy of this surgery in controlling the patients symptoms was also assessed by Visick's grading.
All the patients tolerated this procedure well. Early postoperative stasis related to the operation occurred in one case. This responded to conservative treatment. There was no mortality. No case developed lesser curve ischaemic necrosis or significant general complication of pulmonary infection, urinary or incisional hernia. One patient had a superficial stitch abscess.
All surgeries were fairly accurate with operative time ranging from 40 65 minutes (mean 54). In 2 cases, mucosa was perforated which was overseen without any complications. Blood loss was minimal ranging from 70 to 140 ml (mean 122.2 ml) and hence no patient required blood transfusion.
Post operative evaluation
All patients had immediate relief from ulcer pain. Two patients (6.66%) had early dumping and one patient (3.33%) had diarrhoea which was easily controlled by drugs. All patients were in Visick's grade I except 3 patients who were in grade II. Upper GI endoscopy was carried out after 4 weeks in all the patients. All cases showed evidence of healed ulcer without gastric stasis. Postoperative endoscopic Congo Red test showed completeness of vagotomy in all the cases except in 2 cases where there were small patches of blackening in fundal areas. But this was clinically not significant. Overnight gastric residue was within normal limits in all the patients. Patients were regularly followed up at intervals of 6 months and follow-up ranged from 1 48 months (mean 22.3)
Highly selective vagotomy when first introduced in 19703 was widely regarded as sound application of anatomical and physiological principles of abdominal distribution of parasympathetic system. However, HSV has few inherent procedural problems such as HSV is a time consuming. tedious procedure requiring a higher level of technical skill. Neural elements near esophagogastric junction have to be painstakingly dissected to prevent recurrence. Lesser sac has to be opened to provide access to posterior part of stomach. Lesser curve necrosis is a dreaded complication. Anterior seromyotomy with posterior truncal vagotomy represents a small technical departure from the realm of HW The physiological basis of ASMPTV is that the pylorus is doubly innervated and anterior vagus supplies the posterior part of pylorus as well,. In 40% of cases the posterior vagus does not reach the antrum and stimulation of anterior vagus elicits contraction in posterior part of the stomach wall. Ten percent of the vagal fibres are different and parasympathetic nerves run superficially to the vessels and for a short distance before dipping inside the stomach musculature Overlap reduces likelihood of adhesions and also prevents nerve regeneration. Distension or epigastric fullness due to loss of adaptive relaxation produced by all forms of vagotomy is seen in 50% of patients. This may be compensated for by virtue of interruption of circular muscle along the myotomised segment Posterior truncal vagotomy leads to more complete denervation of stomach, obviating the risk of leaving either the antral corpus or oesophagogastric junctions posteriorly partially innervated. This technique should theoretically lead to a more complete parietal vagotomy and therefore possibly minimise the incidence of recurrent ulceration.
Postoperative evaluation has showed that the results are comparable with that of HSV decrease in basal and maximal acid output have used endoscopic Congo Red test to evaluate completeness of vagotomy and found it as a easy and quick method. Though Congo Red is easy to perform it has its own limitations as some areas are left out of mapping.
The main limiting factor in HSV is recurrent ulceration ranging from 822%, The recurrence is primarily attributable to incomplete vagal denervation of parietal cell mass and can be prevented by the surgeon. Even though ulcer recurrence has not been reported in any of our patients to date, it is still early to predict the efficacy of this procedure as the follow up period in our series has been too short to predict any long-term results. In our study, the incidence of dumping was 6.6% and that of diarrhoea was 3.33%. This is comparable with the reported incidence of 2.7% of dumping and 4.8% of diarrhoea by Tay for et al in ASMPTV.
Hence, we feel that ASMPTV is overall a very safe and a patient compliant procedure. It has overall good recovery rates in terms of control of duodenal ulcer. It is technically easy and can be done even by residents in a short time as is shown in our study. It has minimum postoperative morbidity and preserves near normal stomach when compared with other procedures for duodenal ulcer. With reference to the Indian setting, the satiety value, which is very important because of high fibre content of our food, is lost to a lesser extent in ASIVIPTV due to myotomy of the circular muscle But this needs to be confirmed by a prospective study.
We thank Dr (Mrs) P M Pai, Dean, Seth GS Medical College and King Edward Memorial Hospital for permitting us to publish these data.
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