The Hazards of Antral Exclusion with Vagotomy in theSurgical Treatment of Duodenal Ulcer *

H. WILLIAM SCOTr, JR., M.D., J. LYNWOOD HERRINGTON, M.D.,WILLIAM H. EDWARDS, M.D., HARRISON J. SHULL, M.D.

From the Departments of Surgery and Medicine, Vanderbilt University School ofMedicine, Nashville, Tennessee

DURING the last 12 years, there have de-veloped several surgical approaches to theproblem of duodenal ulcer, which havehad extensive clinical trial in this country.First is the so-called "adequate" subtotalgastrectomy which entails a 70 to 80 percent resection of the distal stomach with-out vagotomy. Second, there is vagotomywith gastroenterostomy as advocated byDragstedt,3 or vagotomy with pyloroplastyas advocated by Weinberg.9 Third, thereis sleeve resection of the acid-peptic bear-ing mucosa of the stomach as championedby Wangensteen.8 The fourth approach,advocated by ourselves 4 and many others,notably Zollinger,"1 Smithwick,5 Coffey 1and their associates, consists of vagotomywith resection of the gastric antrum.Each of these procedures, when properly

executed, provides a surgical means of re-lief of ulcer diathesis, which can lead toexcellent results in the majority of cases.All have the aim of reducing the acidsecretion of the stomach to a normal orsubnornal level. A critical appraisal ofthese varied procedures is thus based ondegrees of excellence and in our opinionnone should be considered as categoricallywrong as an approach to the ulcer problem.Our bias strongly favors vagotomy and

resection of the gastric antrum in treat-ment of duodenal ulcer for several reasons:(1) Both cephalic and gastric phases ofgastric acid secretion are eliminated while50 to 60 per cent of the gastric reservoir is

* Submitted for publication May 4, 1959.

preserved; (2) Definitive therapy may beaccomplished in all presenting forms ofduodenal ulcer, including the complicationsof bleeding and perforation; (3) The oper-ative procedure is technically simple andsafe; (4) The postoperative results areexcellent.

Recently Waddell and Bartlett 7 have de-scribed a method of surgical treatment ofduodenal ulcer which is based on the an-tral exclusion procedure somewhat similarto that advocated by Devine 2 30 yearsago, but with the addition of bilateral sub-diaphragmatic vagotomy. They have re-ported the use of this combination of antralexclusion and vagotomy in a series of 50patients, apparently with encouraging re-sults in a rather short period of follow-up.However, we have serious doubts as to

the fundamental soundness of this proce-dure. Experience with a patient who provedto have residual antral tissue as the causeof multiple recurrences of ulcer followinggastric resection and subsequent repeatedre-resections with vagotomy is reported indetail as evidence for these doubts.

Case SummaryThis 48-year-old white male insurance

executive was admitted to Vanderbilt Uni-versity Hospital on August 31, 1957, owingto attacks of "recurrent ulcer." This was hisfirst admission to Vanderbilt and the his-tory obtained at this time was rather com-plicated and quite interesting. Followingdischarge from Army service, in 1946, thepatient had an unexplained diarrhea of sev-

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182 SCOTT, HERRINGTONeral weeks duration which cleared, withoutspecific medication. Except for this, he hadenjoyed good health all of his life, withno significant illness until 1949 when hebegan to experience vague upper abdom-inal burning pain relieved by foods andantacids. Gastro-intestinal x-ray examina-tion revealed a duodenal deformity. A diag-nosis of duodenal ulcer was made andtreatment consisted of bland diet with littleor no relief. In March 1950, the patient wasadmitted to another hospital because ofacute, severe abdominal pain and the find-ings of an acute abdomen were believedto be due to a perforation of the duodenalulcer. This proved to be the case at opera-tion and treatment consisted of simpleclosure. One month after operation he wasre-admitted to the same hospital becauseof massive upper gastro-intestinal hemor-rhage. In view of his past history, it wasbelieved that the source of bleeding wasmost likely the duodenal ulcer. Operativeintervention was elected and a "50 per centresection with Polya gastrojejunostomy"was performed.

After this operation, the patient did wellfor four months, at which time he had arecurrence of abdominal symptoms consist-ing of mid-epigastric pain and weight loss.A gastro-intestinal series revealed a mar-ginal ulcer; the patient was placed on aregimen consisting of diet, antacids andantispasmodics, but symptoms persisted.For this reason, re-exploration was under-taken in December 1950, at which time asubdiaphragmatic vagotomy with excisionof the stomal ulcer and revision of theanastomosis was carried out. Two vagalnerve trunks were found in the usual loca-tion. Following this procedure the patientgained weight, had no abdominal symp-toms and was able to lead a productive life.However, about 14 months later he noted

the onset of weight loss, lower abdominaldiscomfort and epigastric tenderness. AHollander test for gastric parasympatheticinnervation was positive and an upper

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gastro-intestinal series revealed anothermarginal ulcer. In July 1952, re-explorationrevealed a marginal ulcer and another largevagus trunk innervating the gastric rem-nant was discovered. This was divided andre-resection of the gastric pouch at aslightly higher level carried out. Again thepatient withstood the procedure well, madea good recovery, gained weight and wasasymptomatic.

In December 1954 (18 months after thisoperation), the patient began to loseweight and to complain of epigastric andlower abdominal discomfort. Studies at thistime revealed a marginal ulcer with agastrojejunocolic fistula. Surgical interven-tion was again undertaken and a blockresection of the fistula included high sub-total gastrectomy. After a stormy postop-erative course he made a satisfactory re-covery, gained weight and returned to fullactivity.During the next year the patient re-

mained well, gained weight and seemed tobe doing well. A Hollander test was nega-tive; stimulation with alcohol and hista-mine, however, revealed free acid to bepresent. The patient was asymptomatic. Itwas postulated at this time that the possi-bility of retained antral tissue should beconsidered.

In the spring of 1956, the patient had arecurrence of epigastric burning pain whichlasted for several weeks and responded toantacids and diet. These symptoms re-curred in the spring of 1957 and GI seriesshowed no definite evidence of recurrence,but relief was obtained by an ulcer controlmedical regimen.One month prior to his admission to

Vanderbilt, in August 1957, the patientnoted return of abdominal pain and epi-gastric tenderness, associated with weightloss. For several months prior to this ad-mission, the patient had had a persistent,low grade fever. Re-evaluation at this timewas significant in that there was again anegative Hollander test but 20 degrees of

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FIG. 1. Photograph ofduodenal stump withantral remnant at lastoperation.

,URGICAL TREATMENT OF DUODENAL ULCER

free acid were present after histamine. Agastro-intestinal series was performed withsuggestive evidence of recurrent marginalulceration. In addition, the gastro-intestinalseries revealed a sinus tract extending fromthe region of the stoma into the left upperquadrant. This was believed to be the re-sult of a penetrating marginal ulcer, withsubphrenic cellulitis or abscess accountingfor the temperature elevation.Owing to the severe and persistent tend-

ency to recurrent peptic ulceration in thispatient diagnostic considerations includeda Zollinger-Ellison non-Beta cell islet ade-noma and retained antral tissue. At thistime, a review of the operative record inthe other hospital revealed that at the orig-inal gastric resection a Devine exclusionprocedure had been done. Accordingly, re-tained antral tissue seemed quite likely tobe the problem.On September 17, 1957, re-operation was

undertaken. After exploring the peritonealcavity, careful attention was directed tothe pancreas and the duodenal stump. Thepancreas appeared entirely normal and no

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indication of tumor was present. After theduodenal stump was mobilized, however,it was apparent that a two-cm. stump ofresidual antral tissue was present attachedto the duodenum. This was further sub-stantiated by the palpation of the pyloricsphincter in the duodenal stump (Fig. 1).This residual antral tissue was excised andthe duodenal stump closed. Frozen sectionof the excised specimen revealed gastricand duodenal mucosa to be present. Ex-amination of the small gastric stump andgastrojejunostomy revealed a 1.5-cm. ulcercrater to be present on the gastric marginof the stoma penetrating into the posteriorparietes. A resection of the ulcer wouldhave required a total gastrectomy; conse-quently it was left undisturbed.The postoperative course was afebrile

and remarkably uneventful. Pathologicstudy of permanent sections confirmed thepresence of antral mucosa adjacent to theduodenal mucosa (Fig. 2). The patient wasdischarged on the tenth postoperative daytaking a postgastrectomy diet well.

184 SCOTT, HERRINGTON, EDWARDS AND SHULL

Since this last operation, his subsequentcourse has been most gratifying. In the last18 months his weight has returned to preop-erative levels; he is working daily and thereare no ulcer symptoms. A repeat bariumstudy one month after operation showed nosuggestion of an ulcer crater and disap-pearance of the sinus. Gastric acid studiesrevealed no free acid to be present. Repeatgastro-intestinal series in February 1958and again in February 1959 show no evi-dence of ulcer. A 12-hour collection ofnocturnal gastric secretion in February1959 revealed no free acid and there wasno free acid in response to histamine.

CommentIn the case described above, the evi-

dence appears to be rather conclusive thatthe excluded remnant of the gastric antrumwas responsible for the distressingly per-sistent gastrojejunal ulceration despite sub-sequent radical reduction in the acid-pro-ducing parietal cell area of the stomach andbilateral vagotomy. The prompt healing ofthe patient's fourth anastomotic ulcer afterexcision of the antral remnant and his sub-sequent 18 months of freedom from symp-toms of recurrence are very gratifying tohim and to us (Fig. 3).

Inadvertently, this patient ultimately hadthe same surgical alterations in his gastric

Annals of SurgeryFebruary 1960

FiG. 3. Sequence of operations for duodenalulcer and subsequent anastomotic ulcers in thecase reported. A. Perforation-1950: simple clo-sure; B. Bleeding-1950: 50 per cent resectionwith Devine exclusion of antrum; C. Marginalulcer-1950: vagotomy with revision of stoma;D. Second marginal ulcer-1952: division of resid-ual vagal trunk and additional resection; E. Thirdmarginal ulcer, with gastrojejunocolic fistula-1954:additional resection; F. Fourth marginal ulcer-1957: excision of antral remnant. Composite sketchin center shows progression of gastric resectionwith each operation.

status prior to excision of the excludedantrum which have been advocated byWaddell and Bartlett.7 In discussion oftheir procedure, these authors have stated:"The rationale for the use of antral exclu-sion and vagotomy for the treatment of

FIG. 2. Photomicro-graph of section of ex-cised antral remnant.

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patients with duodenal ulcer is based uponthe premise that the cephalic phase ofsecretion must be minimized or abolishedand that this is the sine qua non of success-ful duodenal ulcer surgery." We are inagreement with the latter part of this state-ment, but we believe they are in graveerror in their reasoning that "transection ofthe stomach and exclusion of the antrumwould eliminate the contact of food withthe antrum and thus eliminate the gastricphase of acid secretion."

In the antral exclusion procedure,whether this be carried out with deliberateintent as in Waddell and Bartlett's patientsor through error as in the patient describedabove, the antral remnant remains attachedto the duodenum and its mucosa is bathedby alkaline duodenal contents. This hasbeen shown to be a stimulus to the elabora-tion of gastrin with resultant increased acidproduction by the parietal cells of the prox-imal gastric stump in numerous studies,and the development of stomal ulcer hasbeen commonly encountered.6' 10 The con-cept of Waddell and Bartlett that this situa-tion will be altered by vagotomy is atvariance with Dragstedt's beautiful experi-ments utilizing vagotomy, the total gastricpouch preparation and antral transplanta-tion. In these experiments the excludedantrum placed in contact with alkalineduodenal or colonic contents caused a sig-nificant rise in the acid production of thegastric pouch despite vagotomy.3The relatively low levels of free hydro-

chloric acid, found in the postoperativeperiod in Waddell and Bartlett's series ofpatients with antral exclusion and vagot-omy, and the apparently diminished re-sponsiveness of the remaining parietal cell-bearing mucosa in these patients to brothand histamine stimulation were interpretedby these authors as strong support of theefficacy of their operation in treatment ofduodenal ulcer. However, it should bepointed out that all their studies are basedon brief (1 to 3 hours) measurements of

gastric secretion and not on the 12-hourquantitative nocturnal collections advo-cated so strongly by Dragstedt. It is ourfear that subsequent follow up of theirpatients, with antral exclusion and vagot-omy, will disclose a distressing incidenceof recurrent ulceration and, based on theclinical and experimental evidence cited aswell as the experience with the patient re-ported above, that it will prove necessaryto remove the residual antrum to controlthe persistent tendency to recurrent ulcer.

References1. Coffey, R. J. and E. J. Lazaro: Vagotomy,

Hemigastrectomy and Gastroduodenostomyin the Treatment of Duodenal Ulcer. Ann.Surgery, 141:862, 1955.

2. Devine, H. B.: Gastric Exclusion. Surg.,Gynec. & Obst., 47:239, 1928.

3. Dragstedt, Lester R.: The Physiology of theGastric Antrum. A. M. A. Arch. Surg., 75:552, 1957.

4. Edwards, L. W., J. L. Herrington, Jr., S. E.Stephenson, R. I. Carlson, R. J. Phillips,W. R. Cate and H. W. Scott, Jr.: DuodenalUlcer: Treatment by Vagotomy and Re-moval of the Gastric Antrum. Ann. Surg.,145:738, 1957.

5. Farmer, D. A. and R. H. Smithwick: Hemi-gastrectomy Combined with Resection ofthe Vagus Nerves. N. Eng. J. Med., 247:1017, 1952.

6. State, David: The Gastric Antrum; Friend orFoe? Surg., Gynec. & Obst., 108:366, 1959.

7. Waddell, W. R. and M. K. Bartlett: AntralExclusion with Vagotomy for DuodenalUlcer. Ann. Surg., 146:3, 1957.

8. Wangensteen, 0. H.: An Acceptable Opera-tion for Peptic Ulcer. Rev. Gastroenterol.,20:611, 1953.

9. Weinberg, J. A., S. J. Stempier, H. J. Moviusand A. E. Dagrodi: Vagotomy and Pyloro-plasty in the Treatment of Duodenal Ulcer.Am. J. Surg., 92(2) :202, 1956.

10. Woodward, E. R., E. S. Lyon, J. Landor andL. R. Dragstedt: The Physiology of theGastric Antrum; Experimental Studies onIsolated Antrum Pouches in Dogs. Gastro-enterology, 27:766, 1954.

11. Zollinger, R. M. and R. D. Williams: Consid-erations in Surgical Treatment for DuodenalUlcer. J. A. M. A., 160:367, 1956.