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95 Vagal Resection for Peptic Ulcer THE LANCET LONDON: SATURDAY, JULY 19, 1947 IT is natural for a sick man to shrink from a surgical operation if medicine can cure him, and the sufferer from peptic ulceration is usually,wise to explore the physician’s resources before undergoing an operation. But where medical treatment has failed surgery will often restore the patient to health. The results of operation nevertheless fall considerably short of, perfection, partly because surgery carries an appreci- able mortality, and partly because though it will cure an ulcer it may fail to prevent a recurrence. Many different operative techniques have been tried in attempts to remedy these defects-to combine safety with maximum reduction of the abnormal acidity and quantity of the gastric juice, which are associated with peptic ulcer. The latest of these techniques is resection of the vagus nerves, and first reports suggest that this may be a major advance. The conception of vagal resection as a treatment for peptic ulcer must be nearly as old as the knowledge that the vagi are responsible for the psychic flow of gastric juice, but it was not until the work and writings of L. R. DRAGSTEDT and his colleagues drew attention to it that the idea caught on. DRAGSTEDT and OWENS 1 showed that, whereas the normal man ceases to secrete gastric juice when he is asleep, the ulcer patient con- tinues to do so throughout the night. This juice, unprovoked by food, must be a psychic flow, mediated through the vagi ; and, undiluted by food, it is the prime factor in causing ulceration, particularly when it is hurried into the duodenum by a hypermotile stomach. DRAGSTEDT hoped in particular to decrease the night flow by vagal denervation of the stomach, and the excellent results of his procedure have been attested by many workers. The immediate effects of section of the vagi are to reduce the quantity and acidity of the gastric juice and the motility of the stomach, and, though all three return with the passage of time to nearly normal, night secretion and hyper- motility are permanently abolished so far as can be judged in the limited time so far available for follow-up of the patients. Section of the vagus probably does more than this. There is evidence (some of it contra- dictory) that it cuts the afferent pathway for stomach and duodenal pain, that it abolishes the spasm of the duodenum which many think is the origin of ulcer pain, and that it severs the nervous connexion between the stomach and the cerebrum. This last may be the key to the success of vagal resection. The evidence for it is the finding by DRAGSTEDT 2 that in man anger or nervous tension immediately and greatly increases the amount of gastric juice which can be recovered from an indwelling Ryle’s tube, an effect which is abolished by section of the vagi. WOLF 3 has amplified these observations by showing that 1. Dragstedt, L. R., Owens, F. M. Proc. Soc. exp. Biol., N.Y. 1943, 53, 152. 2. Dragstedt, L. R. Canad. med. Ass. J. 1947, 56, 133. 3. Wolf, S., quoted by Andrus, W. D. J. Amer. med. Ass. 1947, 133, 748. vagal resection in man abolishes those vascular responses of the stomach to emotion which he and WOLFF described in their classical monograph. The indication for vagal resection is long-standing peptic ulceration which has resisted medical treat- ment. Duodenal ulcers constitute the majority of cases hitherto reported, and typical ulcer patients, who can relate recrudescence of their symptoms to anxiety or stress, are said to do very well. If pyloric stenosis is present, a gastro-enterostomy or pyloro- plasty is an essential addition to the operation ; one could hardly expect a physiological operation on- the vagi to correct anatomical obstruction by old fibrosis. In cases of gastric ulcer vagal resection leads to healing, though some surgeons believe that it should be combined with partial gastrectomy. Gastrojejunal ulceration after gastro-enterostomy or gastrectomy responds well to vagal resection, according to reports, and those who have had to make a .second attack on a stomal ulcer by orthodox techniques will welcome a method of side-stepping its difficulties and perils. Patients who do not do well are those with a bad emotional history, in whom dyspeptic pain is one of many symptoms. One need scarcely add that patients in the throes of an acute gastroduodenal hemorrhage are not suited to vagal resection; but a history of haematemesis or meleena is no bar. The technique of vagal resection is not unduly difficult. The nerves are attacked in the region of the diaphragm. Unfortunately their anatomy is variable at this point. They may appear as two stout nerves, one anterior and one posterior to the oesophagus, or they may be plexiform. Twigs moreover may leave the vagi well above the diaphragm to enter the cesophageal musculature and run therein to the stomach. These anatomical peculiarities have been described by MITCHELL and with special reference to vagus resection by BRADLEY and colleagues 6 and by MILLER and DAVIS. 7 To secure complete vagal denervation of the stomach not less than an inch of the nerves or the plexus should be removed. The approach to this task may be either through the chest or through the abdomen. The thoracic approach has the great advantage that in the absence of pleural adhesions it is easy and total vagal interruption is fairly certain. The greater part of the eighth rib on one or other side is resected, the pleura opened, the pulmonary ligament divided, and the lower inch of the oesophagus mobilised and rotated on a tape as far as is necessary for the identification and resection of the vagal apparatus.- This chest approach however suffers from the disadvantages that a thoracotomy is more perilous than a laparotomy, that pleural effusion and pain in the chest scar often occur, and that the stomach and duodenum are not open to direct inspec- tion. The abdominal approach is technically more difficult, because the surgeon has to work under the high concavity of the diaphragm. The vagi can be sectioned but the cardinal difficulty is to remove a length of all the vagal fibres traversing the oesophageal hiatus. This difficultv can be overcome bv the method described by CR.TLE,s 8 and in this issue ORR and 4. Wolf, S., Wolff, H. G. Human Gastric Function, London, 1944. 5. Mitchell, G. A. G. Brit. J. Surg. 1938, 26, 333. 6. Bradley, W. F., Small, J. T., Wilson, J. W., Walters, W. J. Amer. med. Ass. 1947, 133, 459. 7. Miller, E. M., Davis, C. B. Ibid. p. 461. 8. Crile, G. jun. Cleveland clin. Quart. 1947, 14, 65.

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Page 1: Vagal Resection for Peptic Ulcer

95

Vagal Resection for Peptic Ulcer

THE LANCETLONDON: SATURDAY, JULY 19, 1947

IT is natural for a sick man to shrink from a surgicaloperation if medicine can cure him, and the suffererfrom peptic ulceration is usually,wise to explore thephysician’s resources before undergoing an operation.But where medical treatment has failed surgery willoften restore the patient to health. The results of

operation nevertheless fall considerably short of,perfection, partly because surgery carries an appreci-able mortality, and partly because though it will curean ulcer it may fail to prevent a recurrence. Manydifferent operative techniques have been tried in

attempts to remedy these defects-to combine safetywith maximum reduction of the abnormal acidity andquantity of the gastric juice, which are associated withpeptic ulcer. The latest of these techniques is resectionof the vagus nerves, and first reports suggest that thismay be a major advance.The conception of vagal resection as a treatment for

peptic ulcer must be nearly as old as the knowledgethat the vagi are responsible for the psychic flow ofgastric juice, but it was not until the work and writingsof L. R. DRAGSTEDT and his colleagues drew attentionto it that the idea caught on. DRAGSTEDT and OWENS 1showed that, whereas the normal man ceases to secretegastric juice when he is asleep, the ulcer patient con-tinues to do so throughout the night. This juice,unprovoked by food, must be a psychic flow, mediatedthrough the vagi ; and, undiluted by food, it is the

prime factor in causing ulceration, particularly whenit is hurried into the duodenum by a hypermotilestomach. DRAGSTEDT hoped in particular to decreasethe night flow by vagal denervation of the stomach,and the excellent results of his procedure have beenattested by many workers. The immediate effects ofsection of the vagi are to reduce the quantity andacidity of the gastric juice and the motility of thestomach, and, though all three return with the passageof time to nearly normal, night secretion and hyper-motility are permanently abolished so far as can bejudged in the limited time so far available for follow-upof the patients. Section of the vagus probably doesmore than this. There is evidence (some of it contra-dictory) that it cuts the afferent pathway for stomachand duodenal pain, that it abolishes the spasm of theduodenum which many think is the origin of ulcerpain, and that it severs the nervous connexion betweenthe stomach and the cerebrum. This last may be the

key to the success of vagal resection. The evidencefor it is the finding by DRAGSTEDT 2 that in mananger or nervous tension immediately and greatlyincreases the amount of gastric juice which can berecovered from an indwelling Ryle’s tube, an effectwhich is abolished by section of the vagi. WOLF 3

has amplified these observations by showing that

1. Dragstedt, L. R., Owens, F. M. Proc. Soc. exp. Biol., N.Y. 1943,53, 152.

2. Dragstedt, L. R. Canad. med. Ass. J. 1947, 56, 133.3. Wolf, S., quoted by Andrus, W. D. J. Amer. med. Ass. 1947,

133, 748.

vagal resection in man abolishes those vascularresponses of the stomach to emotion which he andWOLFF described in their classical monograph.The indication for vagal resection is long-standing

peptic ulceration which has resisted medical treat-ment. Duodenal ulcers constitute the majority ofcases hitherto reported, and typical ulcer patients,who can relate recrudescence of their symptoms toanxiety or stress, are said to do very well. If pyloricstenosis is present, a gastro-enterostomy or pyloro-plasty is an essential addition to the operation ; one

could hardly expect a physiological operation on- thevagi to correct anatomical obstruction by old fibrosis.In cases of gastric ulcer vagal resection leads to healing,though some surgeons believe that it should becombined with partial gastrectomy. Gastrojejunalulceration after gastro-enterostomy or gastrectomyresponds well to vagal resection, according to reports,and those who have had to make a .second attack ona stomal ulcer by orthodox techniques will welcomea method of side-stepping its difficulties and perils.Patients who do not do well are those with a bademotional history, in whom dyspeptic pain is one ofmany symptoms. One need scarcely add that patientsin the throes of an acute gastroduodenal hemorrhageare not suited to vagal resection; but a history ofhaematemesis or meleena is no bar.The technique of vagal resection is not unduly

difficult. The nerves are attacked in the region of thediaphragm. Unfortunately their anatomy is variableat this point. They may appear as two stout nerves,one anterior and one posterior to the oesophagus, orthey may be plexiform. Twigs moreover may leavethe vagi well above the diaphragm to enter the

cesophageal musculature and run therein to thestomach. These anatomical peculiarities have beendescribed by MITCHELL and with special referenceto vagus resection by BRADLEY and colleagues 6 andby MILLER and DAVIS. 7 To secure complete vagaldenervation of the stomach not less than an inch ofthe nerves or the plexus should be removed. The

approach to this task may be either through the chestor through the abdomen. The thoracic approach hasthe great advantage that in the absence of pleuraladhesions it is easy and total vagal interruption is

fairly certain. The greater part of the eighth rib onone or other side is resected, the pleura opened, thepulmonary ligament divided, and the lower inch ofthe oesophagus mobilised and rotated on a tape asfar as is necessary for the identification and resectionof the vagal apparatus.- This chest approach howeversuffers from the disadvantages that a thoracotomy ismore perilous than a laparotomy, that pleural effusionand pain in the chest scar often occur, and that thestomach and duodenum are not open to direct inspec-tion. The abdominal approach is technically moredifficult, because the surgeon has to work under thehigh concavity of the diaphragm. The vagi can besectioned but the cardinal difficulty is to remove a

length of all the vagal fibres traversing the oesophagealhiatus. This difficultv can be overcome bv the methoddescribed by CR.TLE,s 8 and in this issue ORR and

4. Wolf, S., Wolff, H. G. Human Gastric Function, London, 1944.5. Mitchell, G. A. G. Brit. J. Surg. 1938, 26, 333. 6. Bradley, W. F., Small, J. T., Wilson, J. W., Walters, W.

J. Amer. med. Ass. 1947, 133, 459.7. Miller, E. M., Davis, C. B. Ibid. p. 461.8. Crile, G. jun. Cleveland clin. Quart. 1947, 14, 65.

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JOHNSON have briefly indicated their method of

enlarging the oesophageal hiatus to reach the posteriormediastinum. Once a satisfactory vagal resectionhas been accomplished all the advantages are with theabdominal approach. Mechanical defects such as

pyloric stenosis can be remedied and gastric carcino-mata or gall-bladder disease will not be overlooked.It seems likely that the thoracic approach will remainuseful for patients who have already undergoneradical surgery of a more usual kind for their pepticulcer and have developed gastrojejunal ulceration.Here the pathology has already been verified, and

exposure from below, difficult enough in the normal,

abdomen, may be impossible when the anatomy isdistorted and obscured by adhesions.

There is general agreement that most patients losetheir symptoms and most ulcers heal after vagalresection. THOMPSON and JAMES, who reported 4cases in these columns last week (p. 44), found that allthe patients were symptomatically relieved and theirgastric acidity showed a substantial fall. In thisissue ORR and JOHNSON report 50 cases. The first15, in which a subdiaphragmatic vagotomy was done,showed the highest proportion of failures, but the latercases, though not reported in detail, were exceedinglysuccessful. They believe that the early failures were dueto incomplete vagal interruption, as judged by theresults of the insulin test-meal which is believed tobe a specific test for vagal denervation of the stomach.Other large series have come from America. CRILE 8

has done 77 cases, often with additional gastro-enterostomy or other mechanical rectification, anddescribes his results as excellent. MooRE and col-leagues 9 have had 1 failure and 3 unsatisfactoryresults in 33 cases. DRAGSTEDT,2 who speaks from thelargest experience of anyone, has done 140 cases, thefirst over four years ago, and he says that vagalresection has replaced all other methods of treatingpeptic ulcers in his clinic.

There are some side effects and dangers associatedwith vagal resection. Transient anorexia and gastricatony follow the operation, but continuous suction forthree or four days will tide the patient over the dangerof acute dilatation of the stomach. Gastric atony maybe a more serious matter if it brings to light a mildpyloric stenosis for which no short-circuiting operationhas been done after the vagal resection. A stomachwhich could cope with some narrowing of its exitbefore vagal denervation may afterwards be unable toempty itself. No constant or serious effect on any ofthe organs distal to the stomach has been found ;diarrhoea sometimes follows the operation but ceasesspontaneously. In some circumstances the balancebetween the abdominal sympathetic and parasym-pathetic .is important and it may be unsafe to tamperwith it. MooRE et al. 9 had one of their cases, a knownhypertensive, die of cerebral haemorrhage nine monthsafter a vagal resection. They suggest that the

unopposed action of the intact sympathetic in theabdomen may have had something to do with thisvascular accident, and they have heard of conversecases where thoracolumbar sympathectomy for hyper-tension has been followed by haemorrhage fromduodenal ulcers. WEEKS et apo report the death of

9. Moore, F. D., Chapman, W. P., Schulz, M. D., Jones, C. M.J. Amer. med. Ass. 1947, 133, 741.

10. Weeks, C., Ryan, B. J., Van Hoy, J. M. Ibid, 1946, 132, 988.

a man suffering from hypertension and peptic ulcerwho had his vagi and his thoracolumbar trunks

resected ; he died of a symptomless perforation of aduodenal ulcer fifteen days after the second operation.No other case of perforation after vagal resectionseems to have occurred, but it may be unwise tatreat the peptic ulcer of a hypertensive by vagalresection or the hypertension of a dyspeptic by thoraco-lumbar sympathectomy. WEEKS et al. also reportanother fatality after vagal resection which is inter-esting. The patient died on the table from cardiaearrest, symptoms of which appeared while the vagiwere being manipulated. The question arises whetherhandling of the vagi has repercussions on the heart,and it would be interesting to know whether cardio.. graphic studies of the heart during dissection of thevagi have been done.Any new technique, especially if founded on

elegant theoretical considerations, will evoke tempo-rary enthusiasm. But though it is too early to pass finaljudgment, it seems that vagal resection will provemore than a passing fashion. If the claims alreadymade for it are substantiated it will have a permanentplace in the treatment of peptic ulcer. Apparently thevagus does not regenerate after it has been cut, and ifthe passage of time shows the effects of resection to bepermanent the operation will become the surgicalanswer to the majority of peptic ulcers.

Life for the Long Lived" AFTER reading many books on old age, I find

Cicero the most irritating," complains Dr. R. ALLENBENNETT in a lively scholarly treatise written fromthe vantage-point of the eighth decade of life. He

objects specifically to the insincerity and lack ofhumour manifest throughout the De Senectute-" this tiresome work." According to Cicero, Catogave four reasons for a miserable old age : havingnothing to do ; enfeeblement of body ; deprivationof pleasure ; and the approach of death. Yet

actually, of these four reasons, only the last isan inevitable result of life, whether long or short. Itis now well established that old people like to be

occupied, that many of their ills yield to treatment,that they take pleasure in simple things, and thatso long as they get these things and can live underconditions of reasonable comfort they pay no

more attention to the thought of death than therest of us.With the account of the measures adopted in

Aberdeen for lightening the burden of age (p. 106),our series of articles on the modern care of old peoplecomes to an end. They show what is being done, upand down the country, to get rid of shoddy standardsof treatment, to replace carelessness by attention tothe welfare of old people, and to restore bodilyfunction and zest for living in those who must depend,to a greater or less degree, on strangers for care intheir later years. Our study has ranged from thosereceiving active treatment in hospital to those livingin institutions, residential homes, almshouses, or

corporation bungalows ; and we have shown how twocities-Glasgow and Aberdeen-are tackling the careof the old from many directions. One vivid lesson

1. Old Age and How to Make the Best of It. Bristol: John Wright.1947. Pp. 23. 2s. 6d.