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While bone disease is occasionally seen after gastrectomy, the influence of vagotomy on calcium and vitamin D metabolism is uncertain. We have, therefore, investigated 23 male patients who had undergone highly selective vagotomy for ulcer 4.3 +/- 1.2 years previously. The 25OHD concentrations were decreased (p less than 0.05), the 1,25(OH)2D concentrations elevated (p less than 0.05) and the immunoreactive parathyroid hormone concentrations normal. Local and total bone mass were normal compared to age-matched men, and there was no biochemical evidence of increased bone turnover. We suggest that the changes in calcium absorption, which are described in the literature after vagotomy, are mediated by 1,25(OH)2D. Although the changes in vitamin D metabolism do not lead to calcium-metabolic disturbances in selected patients, we believe that some will eventually develop vitamin D deficiency and that vitamin D supplementation should be considered.

Of 377 patients with chronic duodenal ulcer undergoing highly selective vagotomy, 13 were splenectomized peroperatively because of capsular tear. 12 of these patients were alive at the time of the subsequent investigation and each was matched with a non-splenectomized patient. The postoperative interval was almost 5 years (median). The splenectomized patients were characterized by their longer hospitalization, and increased blood counts of lymphocytes, monocytes and platelets. Analysis of lymphocyte subsets revealed increased numbers of both T and B lymphocytes after splenectomy. Among the T cells, those with receptors for Fc of IgG were significantly more numerous in the splenectomized group. It is a matter of controversy whether or not this population contains T suppressor cells. Hence further functional investigations are needed to clarify whether our observations bear any relation to the low level of plasma IgM found by us and others in splenectomized individuals. Screening for complement activation by the classical and alternative pathways did not reveal any defects resulting from splenectomy.

Cardiorespiratory changes induced by pneumoperitoneum and head-up tilt may generate alveolar ventilation to perfusion ratio changes and increased systemic vascular resistances. The reliability of end-tidal carbon dioxide tension and pulse oximetry in predicting arterial carbon dioxide partial pressure and arterial oxygen saturation may therefore be affected. The 35 ASA 1-2 patients in this study comprised 12 men and 23 women aged 48 (SD 17) years and weighing 71 (SD 14) kg. Twenty-nine were to undergo upper abdominal laparoscopy for cholecystectomy and six hyperselective vagotomy. Intra-abdominal pressure was 1.7 (SD 0.9) kPa and head-up tilt was 5.6 (SD 4.2) degrees. After abdominal insuflation, arterial carbon dioxide partial pressure significantly increased (p < 0.05). However, the arterial carbon dioxide partial pressure-end-tidal carbon dioxide partial pressure gradient remained constant throughout surgery. This gradient was highly correlated with arterial carbon dioxide partial pressure (p < 0.0001), but was not correlated with elapsed time, intra-abdominal pressure or head-up tilt. Arterial oxygen saturation was always greater than 95% in all patients and the arterial oxygen saturation-pulse oximetric saturation gradient was always less than or equal to +4%. In conclusion, end-tidal carbon dioxide partial pressure and pulse oximetric saturation allow reliable monitoring of arterial carbon dioxide partial pressure and arterial oxygen saturation in the absence of pre-existing cardiopulmonary disease and/or acute peroperative disturbance.

Background: All the risk factors of peptic ulcer disease are not thoroughly understood. Goals: To assess duodenal gastric metaplasia (DGM) in relation to Helicobacter pylori status and endoscopy findings with special reference to the effects of highly selective vagotomy. Study: The study population consisted of 1056 adult patients and an additional 154 patients who had had a highly selective vagotomy. Their clinical and endoscopy records as well as the histology of gastric and duodenal biopsies were evaluated retrospectively. H. pylori infection had been determined by serology and culture. Results: Widespread (more than 20%) DGM was strongly associated with H. pylori positive duodenal ulcer disease (in 59.7% of patients). The prevalence of DGM diminished progressively the more proximally the ulcer was located in the stomach, and was 2.5% in proximal gastric ulcers patients. In vagotomized patients, the prevalence of widespread DGM (8.4% of patients, median 14 years after operation and the majority still H. pylori positive) was close to that of patients with H. pylori gastritis without peptic ulcer disease (4.5%). Conclusions: Widespread DGM is an indicator for an increased risk of duodenal ulcer among H. pylori positive patients and it could be used to select patients for eradication therapy.

In the treatment of duodenal ulcer the hyperselective vagotomy is recommended by the authors. On the other hand it has indications and contraindications which must be taken into account. The rational attitude is that of a differentiated surgical treatment, in which the various methods, classical gastrectomy included, find their indication from case to case.

During Roux-en-Y gastric bypasses (RYGB), some surgeons elect to perform a vagotomy to reduce symptoms of gastro-oesophageal reflux (GER). Routine vagotomy during RYGB may independently affect weight loss and metabolic outcomes following bariatric surgery. We aimed to determine whether vagotomy augments percent excess weight loss in obese patients after RYGB.We examined the effect of vagotomy in 1278 patients undergoing RYGB at our institution from 2003 to 2009. Weight and percent excess weight loss (%EWL) were modelled at three months and annually up to five years using a longitudinal linear mixed model controlling for differences in age, gender, initial body mass index (BMI), ideal body weight, and presence of vagotomy.Vagotomy was performed on 40.3% of our cohort. Vagotomy patients had significantly lower initial BMI (46.4±6.2 vs. 48.3±7.7kg/m(2), p0.001), but there were no other significant differences at baseline. The strongest predictor of %EWL over time was initial BMI, with lower BMI patients exhibiting greater %EWL (p0.001). Age and gender effects were also significant, with younger patients (p0.04) and males (p0.002) attaining greater %EWL. Vagotomy had no effect on %EWL in either simple or multiple regression models.Our series suggest that vagotomy does not augment %EWL when performed with RYGB.

Background: Highly selective vagotomy and complete circular or partial duodenectomy have been applied to complicated duodenal ulcer for many years. These procedures seem to provide better clinical results than truncal vagotomy and antrectomy. Methods: A retrospective analysis was conducted of 120 patients with complicated duodenal ulcer who underwent surgical treatment between 1986 and 1999. Patients with obstruction were treated with either circular complete (17) or partial duodenectomy (3) combined with highly selective vagotomy or truncal vagotomy and antrectomy (37). Those with perforation were treated primarily with highly selective vagotomy and partial duodenectomy, highly selective vagotomy alone, or truncal vagotomy and pyloroplasty. Every patient was followed up either by a clinic visit (75%) or questionnaire to determine the presence of ulcer pain, dumping, diarrhea, vomiting, weight loss, and Visick grade. Results: Long-term follow-up of patients treated with duodenectomy and highly selective vagotomy for obstruction showed that 94% had sustained weight gain whereas more than half of those treated with truncal vagotomy and antrectomy had weight loss. In patients with perforation, duodenectomy and highly selective vagotomy offered no advantage over highly selective vagotomy alone. Conclusions: Highly selective vagotomy and complete circular or partial duodenectomy provide fewer sequelae and better weight gain long term than truncal vagotomy and antrectomy for patients with obstructing duodenal ulcers.

Treatment results of 59 patients with the complicated ulcer disease were analyzed. Authors prove, that in cases of perforative duodenal ulcer, the operation should aim the treatment of all the complications. The use of 2/3 gaster resection in combination with Jadd pyloroplasty and trunk vagotomy led to the decrease of the lethality rate on 21%.

Proximal gastric vagotomy (PGV) has little impact on the normal pattern of solid gastric emptying, despite denervation of the proximal two thirds of the stomach and loss of the proximal gastric pump. In four healthy volunteers and four patients with PGV, we investigated the possible compensatory mechanisms that may come into play after proximal denervation of the stomach. We measured antropyloroduodenal motility with a 10-lumen sleeve/side-hole catheter for 180 minutes after ingestion of a dual-isotope radiolabeled mixed liquid/solid meal. Patients with PGV exhibited faster liquid emptying, but the rate of solid emptying was similar to that in healthy volunteers. The frequency of propagated antropyloric pressure waves was similar between the two groups, but patients with PGV exhibited less isolated pressure waves in the proximal antrum. The amplitude and duration of pressure waves recorded in the distal antrum were significantly increased in the PGV patients as compared to healthy volunteers. Although the pattern of propagated antral contractions and solid gastric emptying remains unchanged after PGV, there is an increase in the amplitude and duration of distal antral contractions, which may compensate for loss of proximal gastric pumping mechanisms.

Background: Open Nissen fundoplication has been the most common surgical treatment of gastro-oesophageal reflux disease (GORD). The present paper describes the symptomatic result, and quantifies the acid reduction achieved by open Nissen fundoplication combined with highly selective vagotomy (HSV) in a consecutive case series. Methods: A study of 106 patients undergoing open Nissen fundoplication and HSV for GORD was performed between 1988 and 1996. A history consistent with reflux was obtained and the diagnosis confirmed with ambulatory oesophageal pH studies and endoscopy. Postoperative pH studies were performed, and peri-operative and late complications were recorded. A standard questionnaire was sent out to patients postoperatively to assess the efficacy of surgery. Results: Pre-operative pH studies were performed on 104 (98%) patients, and on 97 (91.5%) following surgery. There was a highly significant improvement in all parameters of the pH study postoperatively. All symptoms, including bloating and dysphagia, improved significantly postoperatively, except flatulence, which was exacerbated. The majority of patients were very satisfied with their outcome, 82% rating the operation from 80 to 100% successful. Complications were rare and there was no mortality. Conclusions: Open Nissen fundoplication and HSV is an effective method of treating GORD, producing an improvement in symptoms and in ambulatory pH studies.

The technical considerations and preliminary results of 119 patients submitted to laparoscopic highly selective vagotomy are presented. There were 33 with duodenal ulcers, 31 with duodenal ulcers plus gastroesophageal reflux, and 55 with gastroesophageal reflux. Operating time varied from 120 to 160 minutes. Six complications occurred: four perforations of the gastric fundus and two bleeding episodes. Conversion to open surgery was done in four cases and reoperation in one case. No deaths occurred, and the mean hospital stay was 3 days. The mean follow-up was 16 months, being 94% of the cases with Visick I or II and 6% with Visick III or IV. This technique is completely feasible by laparoscopic procedure and reproduces exactly what has been done with the laparotomy approach.

The purpose of this review is to assess the position of laparoscopic gastric surgery. Only for perforated gastric and duodenal ulcers a prospective randomized study is available without revealing meaningful differences between conventional and laparoscopic procedure. The elective laparoscopic Selective Proximal Vagotomy (SPV) of stomach and duodenal ulcers was reported on some 200 patients till now. The perioperative risk was lower than that of the conventional method. Due to only short follow-up statements on the risk of ulcer recurrence and therefore completion of vagotomy can not be made. Because of operative technical difficulties some examinators have modified the Selective Proximal Vagotomy, but long-term results with these techniques and the conventional method do not exist. Till now a laparoscopic resection of the stomach was done in less than 100 patients. At comparable risk of both methods representative conclusions could not be made. Similar small are the experiences with laparoscopic resection of the stomach or gastrectomy for gastric carcinoma. The results suppose that a systematic lymph node dissection of the compartment II is only restrictevly possible. The operative risk is nearly that of the conventional method. Laparoscopic staging is a favourable indication in gastric surgery with the aim to detect peritoneal metastases and to spare the patient an exploratory laparotomy. Furthermore, laparoscopy offers advantages in palliative procedures, without existence of extensive proof. Nowadays it is applied for extreme obesity and "Gastric Banding", a method with low perioperative risk. Whether the long-term results are equivalent to those of conventional stomach bypass operations is not proved so far. Alltogether the advantages of laparoscopy in comparison to conventional gastric surgery are only obvious in a few clinical situations. Qualified randomized prospective studies are necessary to evaluate the new operation techniques.

Early studies suggested that gastric surgery for benign ulcer disease was associated with a subsequent increase in the risk of large bowel cancer. Dietary fats, altered bacterial flora, and secondary bile acids are considered to play a major role in the disease etiology. Gastric surgery is known to alter bile salt metabolism as well as bacterial flora in the colon. This cohort study was designed to investigate the risk of large bowel cancer following gastric surgery for benign ulcer disease and to identify potential patient and treatment characteristics that may be associated with this risk. A cohort of 15,983 males was selected from Department of Veterans Affairs hospital admissions in 1970 and 1971. The exposed group (n = 7,609) included all males treated with gastric surgery (resection or vagotomy and drainage) for benign ulcer disease. The unexposed group (n = 8,374) was a random sample of all other male patients from the same time period and database. All subjects were followed through 1989 to identify vital status and cause of death. Deaths were identifiable by computerized linkage of the subjects' social security numbers with the Department of Veterans Affairs Beneficiary Identification Record Locator System and the National Death Index. The cause of death was documented by two certified nosologists from the death certificates of 99% of the deceased patients. Statistical analyses included estimations of risk based on standardized mortality ratios and standardized risk ratios. In this selected cohort, no increase in large bowel cancer risk was detected (risk ratio = 0.81, 95% confidence interval 0.62-1.05). The type of surgical procedure, ulcer diagnosis, age at the time of surgery, and length of follow-up did not alter the risk estimates. Unlike the previously identified increase in gastric cancer risk following ulcer surgery, no elevation in the risk of large bowel cancer following such surgery was detected in this study. Factors that may alter gastric surgery sequelae and resultant site-specific cancer risks deserve further investigations.

Background/aims Indications for surgery in patients with duodenal ulcers have changed radically. Gastric outlet obstruction (GOO) is a complication that can result from duodenal ulcers. From the perspective of organ preservation, gastroduodenostomy (e.g. Jaboulay procedure) is ideal for the treatment of GOO due to duodenal ulcer-induced stricture; however, delayed gastric emptying is frequently observed postoperatively. We compared the short-term clinical outcomes of Jaboulay procedure with those of antrectomy. Methodology We retrospectively studied 30 patients who underwent surgery for GOO due to duodenal ulcer. The patients were divided into the J group (those who underwent highly selective vagotomy with Jaboulay gastroduodenostomy) and the A group (those who underwent highly selective vagotomy and antrectomy with Billroth II reconstruction). Results The mean duration of nasogastric suction, number of days until diet initiation, number of days until oral ingestion of solid food and postoperative duration of hospitalization were significantly shorter in the A group than in the J group. Moreover, delayed gastric emptying was significantly less frequent in the A group than in the J group. Conclusions Considering the short-term postoperative outcomes, we believe that highly selective vagotomy and antrectomy with Billroth II reconstruction are the preferred procedures for duodenal ulcer-induced GOO.

Antireflux surgery in recent years become a standard treatment for complicated forms of gastroesophageal reflux disease (GERD). Complicated forms of GERD are usually the result of the availability of hiatal hernia (HH). Acquired shortening of the esophagus is a natural complication of severe reflux esophagitis developing on a background of sliding HH. Among surgeons disagree about the appropriateness of the laparoscopic antireflux interventions for patients with a shortening of the esophagus. On the basis of the Central Research Institute of Gastroenterology 35 patients were performed to laparoscopic surgery by truncation of the esophagus. Analysis of results showed the efficacy and safety of laparoscopic access for treatment of reflux esophagitis in patients with the esophagus truncation.

Barrett's oesophagus is a condition when the oesophagus adenocarcinoma risk increases. There are different ways of diagnostic and treatment for this disease abroad and our country. We offer a complex method for Barrett's oesophagus treatment. Our method reveals Barrett's oesophagus effectively. We also take antireflux treatment and Barrett's epithelium elimination using miniinvasive surgery with drugs therapy. We have experience of curing 48 patients from Barrett's oesophagus. Considering obtained results our tactic for clinical practice is recommended.

The aim of our investigation was to study the influence of the systematic enzymotherapy on the results of surgical treatment of patients with duodenal ulcers. The immunological investigation was conducted on 77 patients with duodenal ulcers. The obtained results reveal the changes of immunological indexes in patients with duodenal ulcers. The process of rehabilitation with immunomodulative and enzymatic therapy after surgical treatment is analyzed and described.

There is an increased risk of gastrointestinal carcinoma and smoking-related diseases after partial gastrectomy for peptic ulcer disease. The purpose of this study was to evaluate long-term cancer incidence and mortality after parietal cell vagotomy (PCV), a surgical method with a low rate of side effects, but creating hypochlorhydria in the stomach mimicking long-term treatment with antisecretory drugs.Data on 383 ulcer patients operated on with PCV during 1971-80 at Lund University Hospital were compared with the national registers for cause of death and cancer incidence for selected diagnoses. Median follow-up was 28 years and 31 years, respectively. Standardized mortality ratios (SMRs) and standardized incidence ratios (SIRs) were calculated.An increased incidence of cancer in the respiratory organs (SIR 1.97, 95% CI: 1.08-3.31) and prostate carcinoma (SIR 1.85, 95% CI: 1.22-2.69) was found, and among men also an increased mortality in prostate carcinoma (SMR 3.85, 95% CI: 1.41-8.38) and chronic respiratory disease (SMR 2.76, 95% CI: 1.01-6.02). Overall mortality was similar to that of the background population and no increased risk of gastrointestinal malignancies was observed.Patients with peptic ulcer operated on with PCV have a long-term increased risk of smoking-related diseases, but PCV does not seem to increase the risk of gastrointestinal carcinoma. An increased risk of, and mortality in prostate carcinoma was found, a cancer previously not found to be related to smoking. This might be the result of surgery-induced hypochlorhydria, which warrants further investigation in patients on long-term proton-pump inhibitors.

The literature data and the results of own investigations on gastric recurrent ulcers occurrence after organpreserving operations performance for the ulcer disease are summarized. The data on gastric recurrent ulcers occurrence rate are adduced. Modern views on possible causes of occurrence, necessary volume and informativity of investigation methods and tactics of treatment are presented. Gastroduodenal motor-evacuation function disorders, duodenogastric reflux and gastric hypersecretion are suggested as a most frequent causes of gastric recurrent ulcers occurrence. The method of operative intervention choice for recurrent gastric ulcer is determined by the cause of its occurrence, as well as the character of ulcer complication and the kind of previous surgical procedure performed.

The serum gastrin response to an infusion of gastrin-releasing peptide (GRP), with or without simultaneous fundic distension, was studied in healthy volunteers and in patients with duodenal ulcer disease before and after a complete proximal gastric vagotomy (PGV). We also studied the effect of fundic distension alone on gastrin release and intraluminal gastric pressure in healthy volunteers and in patients after PGV. We observed an increased intraluminal pressure in patients after PGV compared with healthy subjects. During fundic distension with 600 ml of air no significant increase in gastrin values was observed in healthy subjects or in duodenal ulcer patients. In healthy subjects fundic distension significantly inhibited the gastrin response to the higher dose of GRP. This inhibitory effect exerted by fundic distension was counteracted by cholinergic blockade. In contrast, fundic distension did not alter the gastrin response to GRP in duodenal ulcer patients, suggesting a defective inhibitory mechanism in duodenal ulcer patients. After PGV, GRP infusion resulted in an enhanced gastrin response, and fundic distension seemed to facilitate the gastrin-stimulatory effect of GRP. This supports the concept of a vagally dependent inhibitory oxyntopyloric mechanism and that fundic distension can elicit both inhibitory and stimulatory secretory mechanisms.

The function of esophago-gastric junction is studied in 147 patients with ulcer pyloroduodenal stenosis before and after the selective proximal vagotomy (SPV) procedure. The frequency of reflux-esophagitis was 71.9%. It is determined that reflux develops due to gastric evacuatory disorders, reduction of lower esophageal sphincter tone and contraction of abdominal part of esophagus. Reflux-esophagitis develops as the consequence of aggressive gastric juices action on the esophageal mucosa. Authors reconstruct the esophageal sphincter mechanism by performing the modified fundoplication and fundoesophagocruropexy.

The relationship between suppressed gastric acidity and the increase in plasma gastrin levels after pharmacological and surgical treatment of peptic ulcer disease were compared in this study. Eight patients with chronic duodenal ulcer and referred for proximal gastric vagotomy were studied. 24-hour intragastric acidity and plasma gastrin levels were investigated in the same patients on three consecutive occasions: preentry without any treatment; after 4 weeks of administration of 20 mg of omeprazole daily, and 4–6 months after proximal gastric vagotomy. Intragastric acidity was slightly more reduced by omeprazole (94%) than after proximal gastric vagotomy (78%), with no difference found during the day or night with either. Plasma gastrin levels increased slightly more after proximal gastric vagotomy [284% (median, 2120 pmol · h/L; range, 733–2831 pmol · h/L)] than after omeprazole administration [186% (median, 1586 pmol · h/L; range, 495–2573 pmol · h/L)]. There is strong evidence that the increased plasma gastrin concentration following omeprazole treatment is caused by the reduced intragastric acidity. The slight increase in plasma gastrin concentration following proximal gastric vagotomy despite a lesser reduction in intragastric acidity may be the result of additional effects on gastrin release by the vagotomy. Both treatments resulted in a modest increase in plasma levels of gastrin that were far below the gastrin levels observed in achlorhydric patients, e.g., patients with pernicious anemia.

The influence of intragastric pH on the basal release of somatostatin has been studied in healthy controls and in duodenal ulcer patients. In addition the somatostatin response to gastrin-releasing peptide infusion has been evaluated both regarding the effect of intragastric pH and the influence of vagal innervation and muscarinic blockade. No difference was found in basal blood levels, when changing the intraluminal pH, although a slightly higher basal somatostatin concentration was noticed in patients with duodenal ulcer disease. Neither proximal gastric vagotomy nor cholinergic blockade had any effect on basal somatostatin concentrations. GRP infused in stepwise increasing doses from 20 pmol/kg/h to 400 pmol/kg/h induced a small but significant response. This effect of GRP was most evident, when the stomach was perfused with 0.1 M HCl. The small, somatostatin response to GRP infusion was not influenced by vagal denervation of the parietal cell area, neither by cholinergic blockade. Despite the previously observed effects of vagotomy and cholinergic blockade on gastrin release induced by GRP, a corresponding inverse effect on somatostatin is not apparent.

Ninety-seven consecutive patients with gastric surgery for peptic ulcer were studied; 86 had duodenal ulcer (DU), and 11 gastric ulcer (GU). DU patients were surgically treated by proximal vagotomy, proximal vagotomy and pyloroplasty, truncal vagotomy and pyloroplasty, or truncal vagotomy and antrectomy. All GU patients were operated on by the Billroth I method. Serum pepsinogen I(S-PG I), serum pepsinogen II (S-PG II), basal acid output (BAO), and maximal acid output (MAO) were determined before and 3 months and 1 year after the operation. The mean preoperative S-PG I concentration in DU patients (154 +/- 7 micrograms/l; mean +/- SE) was significantly higher than that (97 +/- 9 micrograms/l) in GU patients (p less than 0.001). A significant decrease in the mean S-PG I concentration in DU patients was seen 3 months (92 +/- 6 micrograms/l) and 1 year (66 +/- 4 micrograms/l) after the operation (p less than 0.001). This change did not depend on the type of vagotomy. However, this decrease was not seen in all individual patients as it was in BAO values. Moreover, the mean BAO decrease was much greater at 3 months (7% of the preoperative value) and 1 year (23%) after the operation than the respective decrease in S-PG I concentration. There was also no correlation between S-PG I and acid output (BAO and MAO) before and after the operation. In GU patients the decrease in mean S-PG I value after the Billroth I operation was smaller than in DU patients after vagotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Duodenogastric bile reflux was determined by nasogastric aspiration in 60 patients with prepyloric, pyloric, or duodenal ulcer before and after selective proximal vagotomy (SPV) or SPV and pyloroplasty (PP). All patients underwent two aspiration tests before and 3 months, 1 year, and 3 years after operation. The highest 1-h output of bile acids was recorded, and 100 mumol x h-1 or more was considered a positive reflux test. Sixteen patients (27%) had positive tests before operation; seven of them had previously been cholecystectomized. Forty-four patients (73%) had negative tests preoperatively; one had been cholecystectomized. Of 43 non-reflux patients without previous cholecystectomy 21 were randomized to SPV and 22 to SPV + PP. Sixteen patients (76%) remained negative after SPV, and 19 of 22 (86%) after SPV + PP. The incidence of negative bile reflux before and after SPV or SPV + PP did not differ. Cholecystectomized patients had a high incidence of bile reflux before (seven of eight) and after (six of eight) SPV or SPV + PP. It is concluded that neither SPV nor PP causes bile reflux.

Highly selective vagotomy for duodenal ulcer was performed on 307 patients between 1973 and 1983 without operative mortality. Of these, 283 (92·2per cent) were followed up prospectively for a minimum of 5 years. Recurrent ulcer was diagnosed in 49 (17·3per cent). The recurrent ulcer rate increased from 13·2per cent at 5 years to 19·4per cent at 12 years. Age, length of history, previous haemorrhage or perforation and preoperative acid output were not associated with increased risk of recurrent ulceration. The risk in men and smokers was higher but not significantly so. The recurrence rate for individual surgeons varied from 5·3 to 25·6 per cent. Failure of healing with H2-receptor antagonists was not associated with a higher recurrent ulcer rate. Patients with a strong family history (more than one first degree relative affected) had a significantly higher recurrence rate (33·2per cent at 10 years) than those without (13·5per cent at 10 years). Of the 49 recurrent ulcer patients, 30 (61·2per cent) required either an operation or regular H2-receptor antagonists. Of the 250 patients (81·4per cent) available in 1988 for review of symptoms 5–15 years after operation, 5·4per cent had dumping, 8·9per cent epigastric pain, and 11·8per cent heartburn every day or most days. H2-receptor antagonists were required by 10·7 per cent of patients on a frequent or regular basis. Of 239 patients who answered the question, 218 (91·2per cent) felt that their symptoms had been cured or greatly improved and 203 (84·9) considered the operation a success. Despite the high recurrence rate, the operation was successful in controlling ulcer symptoms in around 90 per cent of patients and produced postvagotomy symptoms - none severe - in around 5 per cent of patients.

INTRODUCTION Nissen fundoplication (NF) has not been a uniformly successful treatment for gastroesophageal reflux disease (GERD). Acid lowering procedures such as highly selective vagotomy (HSV) have not yet been fully evaluated as an adjunctive treatment. NFHSV was evaluated in GERD. MATERIALS AND METHODS Between June 2003 and June 2005, 8 women with a history of 6 months of GERD unrelieved by medication, preprandial pain, peptic ulcer disease, or severe gastritis underwent laparoscopic NFHSV. They have been followed for a mean 12 months. Preoperative and postoperative Heartburn Severity scores (HSS) were obtained. RESULTS Mean operative time was 110 minutes. There were no complications. One patient needed postoperative proton pump inhibitor, which was discontinued after smoking cessation 5 months after NFHSV. All 8 patients showed marked improvement in symptoms and HSS. CONCLUSIONS This series lends credence to the notion that NFHSV was effective. Several studies need to be performed to demonstrate the full efficacy and safety of this approach.

To evaluate the long-term therapeutic efficacy of extended parietal cell vagotomy (EPCV) in the treatment of duodenal ulcer complicated with acute perforation.Therapeutic efficacy of EPCV in 176 cases subjected to duodenal ulcer with acute perforation since 1979 was evaluated, including postoperative complication, ulcer recurrence rate, gastric empting function, endoscopic and radiographical examination, nutritional status and Visick classification.Among 176 patients, 153 (86.9%) cases were successfully followed-up for 5 years after operation. No operative death was found. Postprandial superior belly fullness occurred in 13 cases (8.5%) and heartburn in 12 cases (7.8%), which could be relieved by Domperidone. Adhesive ileus was noted in 4 cases (2.6%) which was cured by adhesiolysis. The total ulcer recurrence rate was 2.6% (4 cases) within 2 to 3 years after operation. Superficial gastritis occurred in 21 cases (13.7%) and duodenal bulb in 31 cases (20.3%). Sinus ventriculi vermicular motion was good and gastric emptying was normal. No anemia was found. Body weight gained in 116 cases (75.8%). One hundred and forty-six cases(95.4%) were reforming Visick grade I and II , 3 cases(2.0%) grade III , and 4 cases (2.6%) IV .EPCV is convenient for performance with low postoperative complication rate. Its long-term efficacies are quite good, which including normal nutritional status, high quality of life and low ulcer recurrence rate. EPCV is one of effective and safe treatments for duodenal ulcer complicated with acute perforation.

Selective vagotomy and antrectomy (SV-A) is performed as a surgical treatment in patients with pyloric stenosis due to peptic ulcer. Since this method shows that the incidence of postoperative complaints is not low, various reconstruction methods have been evaluated to prevent the sequelae. However, there have been no definitely useful methods. A jejunal pouch reconstruction used for gastric cancer surgery has been performed to compensate for the disadvantages of SV-A in 7 patients with complicated gastric, duodenal ulcers at this study. A 10- to 15-cm-long pouch is interposed between the remnant stomach and the duodenum. The pouch is anastomosed to the duodenum using the double tract method. The median postoperative follow-up period was 61 months. No patients showed gastric stasis, ulcer recurrence, residual gastritis. We demonstrated the method of jejunal pouch double tract reconstruction after SV-A. This method was useful for preventing the sequelae after SV-A.

Simultant surgical treatment of 310 patients, suffering the duodenal ulcer disease, complicated by perforation and reflux-esophagitis, was conducted. There was performed of perforated ulcer dissection, pyloroduodenoplasty, selective proximal vagotomy, fundoplication. The results of treatment of 245 patients in terms from 6 mo up to 20 yrs were studied up. Good and satisfactory results were noted accordingly in 94.6 and 3.4% of observations. Duodenal ulcer disease recurrence have occurred in 6 (2%) of patients. The reflux-esophagitis recurrence was not observed. All the patients have survived.

BACKGROUND Several operations are useful for peptic ulcer surgery, these include Vagotomy and pyloroplasty, Vagotomy and antrectomy, Vagotomy and gastrojejunostomy, and Highly Selective Vagotomy to name a few. Utilising any of these procedures may be due to the operator's preference or more importantly the suitability of the operation to the individual patient. This study was carried out to see the surgical presentation of chronic peptic ulcer disease patients and the form of ulcer-surgery utilised in the University College Hospital Ibadan, Nigeria. STUDY DESIGN A retrospective study of all the patients who were operated on for complications of peptic ulcer disease between January 1990 and December 2003 at the above-mentioned institution by studying the case-files, ward admission records and operation room registers of such patients. RESULT There were 122 patients, 90 male and 32 female with a Male:Female ratio of 3:1. Pyloric stenosis accounted for 56.6% of patients followed by perforation (29.5%), bleeding (9.8%) and gastric ulcer (4.1%). Yearly presentations seem to be reducing. Truncal vagotomy and drainage was performed in 78.64% of the patients, simple closure for perforation in 29.5%, partial gastrectomy for 4.1% while the remaining 2.4% had underunning of a bleeding vessel. CONCLUSION Pyloric stenosis (also called gastric outlet obstruction) is the most common surgical presentation of peptic ulcer disease in the University College Hospital Ibadan and Truncal Vagotomy and drainage is the most common surgical procedure performed for peptic ulcer.

One hundred and twenty-six patients aged 14 to 88 years underwent surgery concerning perforative ulcer os stomach and duodenum. Forty-seven patients had symptoms of stenosis including 23 patients with penetration. It is demonstrated that vagotomy, incision of ulcer with duodenoplasty or pyloro-duodenoplasty permit to treat successfully perforative ulcers and to achieve good functional results in long-term period.

To investigate changes in the histology and the Helicobacter pylori (H. pylori) prevalence and density of the gastric mucosa, as well as in fasting serum gastrin and serum pepsinogen I, depending on completeness of vagotomy, and in cases of recurrent ulcer, during 14 years after operation in duodenal ulcer patients.122 vagotomized duodenal ulcer patients were studied twice on average 9 and 14 years after operation. The presence of recurrent ulcer and completeness of vagotomy were assessed simultaneously endoscopically and by endoscopic Congo red test. The histology of the gastric antrum and corpus mucosa was assessed in accordance with the Sydney system. The amount of H. pylori in the specimens was detected by microscopic counting; gastrin and pepsinogen I in serum were determined radioimmunologically.During the 14-year follow-up period, complete vagotomy patients were characterized by a smaller amount of active antrum gastritis and a larger amount of active chronic corpus gastritis involving corpus atrophy in 46% of cases 14 years after operation. Recurrent ulcer patients were characterized by a significantly higher prevalence of high-grade H. pylori colonization and active mucosal inflammation in the antrum as well as by a lower level of active mucosal inflammation and atrophy in the corpus and a higher serum pepsinogen I level compared with complete vagotomy cases. The data of incomplete vagotomy patients without recurrent ulcer became more similar to those recorded for recurrent ulcer patients.In duodenal ulcer patients, changes in the histology of the gastric antrum and corpus mucosa as well as in H. pylori prevalence and density and in serum pepsinogen I levels are different depending on completeness of vagotomy during 14 years after operation.

The article gives an analysis of the surgical treatment of perforative gastroduodenal ulcers. Out of 185 patients in 143 (77,2%) cases took place operation on taking in a perforative hole when 9 (6,2%) patients, five of them above 60, couldn't get it over. It has to be noted that the mentioned 9 patients were taken to the hospital after 521 (five hundred and twenty one) hours the perforation had started, each of them after 58 (fifty eight) hours in average. At the same time for patients below 60 were taken to the hospital after 38 (thirty eight) hours, patients above 60 (sixty) after 74 (seventy four) hours. So one of the main causes of death was later hospitalization. This approach considerably reduces ulceroraphy due to the active implementation of the radical treatment methods. According to above given dates, the approach considerably reduces ulceroraphy due to the active implementation of some radical surgical treatment methods.

Before being superseded by medical management, highly selective vagotomy (HSV) without drainage was the procedure of choice for uncomplicated duodenal ulcer. It is also justified for complications, including perforation and bleeding in selected cases. This prospective study evaluated the effects of HSV plus drainage on solid gastric emptying in 20 patients with chronic duodenal ulcer and pyloric stenosis. Patients were treated with HSV plus pyloroplasty (Heineke-Mikulicz pyloroplasty in five patients, Finney pyloroplasty in six patients and Jaboulay gastroduodenostomy in nine patients) and underwent solid-phase gastric emptying scintigraphic studies pre-operatively and 2 months and 6 months post-operatively. Results were compared with those from 10 controls. No significant differences were observed between the different types of pyloroplasty, although emptying was slightly faster in the gastroduodenostomy group. Gastric emptying returned to normal by 6 months post-operatively. In conclusion, HSV plus pyloroplasty is effective and can be used for the relief of stenosis in selected cases of duodenal ulcer.

Experience in surgical treatment of 261 patients with complicated gastroduodenal ulcer is summarized. A new improved method of resection with subtotal excision of the small curvature and selective gastric vagotomy, creation of a gastric stump in the form of a proximal reservoir and distal tubular canal was used. In 144 cases this method was performed as repeated or reconstructive surgery in post-vagotomic ulcers. The follow-up was 5 years, long-term results were evaluated in 166 patients with the Visik scale. Excellent and good results were seen in 151 (91%) patients, satisfactory -- in 13 (7.8%), and a poor result (recurrence of ulcer) -- in 2 (1.2%) patients.

Experience in surgical treatment of bleedings from varicose veins of the esophagus and stomach is analyzed. Two new methods of azygo-portal separation are offered, indications and contraindications, main principles of treatment before and after surgery, short- and long-term results are described.

The intraoperative measures preventing functional complications after vagotomy were determined in performing organ-saving operations on 63 patients with complications of ulcer disease of the duodenum. Truncal vagotomy must be supplemented with draining operation. The draining operations should be carried out with the dissection of the cicatricial-ulcerous infiltration. The gastroduodenal anastomosis in draining operation should be formed by a one-row suture. When performing selective proximal vagotomy and its variants it is necessary to avoid iatrogenic damage of the Laterge nerve and its terminal part--"crow's feet". Mobilization of the abdominal part of the esophagus during different variants of selective proximal vagotomy must be fulfilled along the length not more than 5 cm proximal to the gastro-esophageal passage and to be associated with a correcting operation on the esophagocardial part.

Despite a decreasing number of operations for ulcer, there are many patients who require definitive treatment. If an operation is required for duodenal ulcer, vagotomy of some type is part of the treatment, and in gastric ulcer resection with or without vagotomy is required. Extended proximal gastric vagotomy can be performed in the majority of patients, excluding those who are unstable or have severe concomitant diseases. In cases of urgent surgery for hemorrhage or perforation, the surgical procedure must be selected individually. Although the role of traditional operations is well established, there is increasing interest in laparoscopic approaches. However, because there is a diminishing of elective surgery for ulcer, it is unlikely that these new procedures may be evaluated as operations were evaluated in the past.

Results of two surgeries--total and subtotal resection of pancreatic head in combination with selective proximal vagotomy (SPV)--performed for chronic pancreatitis and duodenal ulcer disease (DUD) are presented. In one case surgery was supplemented with circular resection of the duodenum and fundoplication. Reconstructive stage of both surgeries included creation of pacreato- and biliodigestive anastomosis on Roux intestinal loop. Choledochojejunoanastomosis was created on the same loop of the small intestine either "end-to-side" with supraduodenal part of common bile duct or "side-to-side" with its pancreatic part. The former surgery was finished with duodenoduodenoanastomosis "end-to-end" for recovery of duodenal passage. This surgery was characterized by complete removal of pancreatic head. The latter surgery corresponded to Beger's operation. There were no complications in the nearest postoperative period. Long-term results were favorable and followed up during 17.5 and 7 months, respectively. This experience testifies that resection of pancreatic head with SPV may be considered as alternative to pancreatoduodenal resection in surgical treatment of patients with chronic pancreatitis.

Between 1978 and 1992, 61 patients were operated on for new or recurrent problems after antireflux surgery. Indications for reoperation were recurrent reflux in 50 patients (associated with dysphagia in 14), dysphagia alone in six and postprandial pain in five. At reoperation the cause of the problem was apparent as anatomical breakdown of the repair in 19 patients, gastric pull-through (slipped Nissen procedure) in 14 and paraoesophageal hernia in six. In 18 patients the cause of the symptoms was not readily apparent. Reoperation consisted of fundo-plication alone in 27 patients, fundoplication with pyloroplasty in eight, fundoplication with proximal gastric vagotomy in four, a Collis–Nissen procedure in 11 (four also had pyloroplasty), a Roux-en-Y procedure in four, total gastrectomy in one and reduction of a paraoesophageal hernia in six. Of the 20 patients with some form of destruction of the gastric outlet six experienced troublesome dumping symptoms and in two this was severe. Two patients died from cardiac causes after surgery. Of the remaining 59 patients, 51 rated the procedure as successful. Repeat antireflux procedures can give results almost as good as those of primary antireflux surgery. However, pyloroplasty and gastric resection should be avoided if at all possible.

To study the long-term results of selective vagotomy plus antrectomy in treatment of duodenal ulcer.One hundred and ninety-three patients with duodenal ulcer were subjected to selective vagotomy plus antrectomy from November 1977 to November 2001. These patients included 28 patients with refractory ulcer, 112 with recurrent bleeding, 41 with pylori obstruction, and 12 with duodenal and gastric ulcer.BAO, IMAO, PMAO and serum gastrin were decreased significantly after an 1 - 24-year follow-up after selective vagotomy plus antrectomy. The characteristics of inhibitory secretive were observed in parietal cells. Follow-up after operation for 1 - 10 years and 11 - 24 years showed that 95.60% and 96.61% of patients belonged to Visick grade I and II, and 4.40% and 3.39% of patients belonged to Visick grade III, respectively. No ulcer recurrence was seen during the 1 - 24 year follow-up after the operation.SV + A is an effective method for duodenal ulcer, especially for complicated duodenal ulcer, with permanent reduction of gastric acid and no recurrence.

To study the long-term curative effects of suture plus proximal gastric vagotomy (PGV) and suture plus triad-therapy (omeprazole, amoxycillin and flagyl taken orally) for the treatment of duodenal ulcer with acute perforation.Three hundred and twenty-nine patients with duodenal ulcer and acute perforation were treated with 2 different methods, respectively. Method A was suture plus PGV (group A, 153 cases), and method B was suture plus triad-therapy (group B, 176 cases). Follow-up was made by means of correspondence, outpatient reexamination and cooperation with local hospitals in 5 to 8 years after operation. The contents of follow-up included symptom acquisition (such as upper abdominal pain or distention, pyrosis, belch, acid regurgitation, vomiting, diarrhea and conditions of living or working), gastroscopy and Helicobacter pylori (HP) detection. The curative effects were evaluated by the Visick scale.Three hundred and one patients were followed up (group A 142 and group B 159). According to the Visick scale, 97 (68.3%), 19 (13.4%), 13 (9.15%) and 13 (9.15%) patients in group A, and 31 (19.5%), 28 (17.6%), 24 (15.1%) and 76 (47.8%) in group B were classified as Visick I, II, III and IV respectively (Z = -9.818, P0.01). As for HP detection, there were 130 (91.5%) patients in group A and 94 (59.1%) in group B (chi(2) = 41.438, P0.01).The long-term curative effects of suture plus PGV were superior to those of suture plus triad-therapy for duodenal ulcer with acute perforation although HP positive rate was higher in group A than in group B. HP infection is one of the etiological factors of duodenal ulcer. The increased excitability of the vagus nerve remains to play an important role in duodenal ulcer.

Blood plasma insulin has been studied in 74 patients with gastroduodenal peptic ulcer (GDU) with the aid of the radioimmunological method before the operation, in the early and remote postoperative periods. Prior to surgery, the level of insulin gets increased on an empty stomach and after stimulation both in gastric and in duodenal peptic ulcer. The hormone content has been found to be reduced postoperatively, both in the immediate and remote periods but pyloroplasty in selective proximal vagotomy and especially in selective vagotomy resulted in a greater increase in insulin following its stimulation with test breakfast. Rehabilitative measures before and after surgery have been shown to be associated with augmentation of the blood level of the hormone, which fact promotes increase of the trophic effect of insulin on the gastrointestinal system.

The completeness of vagotomy following proximal gastric vagotomy or anterior seromyotomy with posterior truncal vagotomy was assessed prospectively in 48 patients using the intraoperative congo red test. Pentagastrin (6 μg/kg) was given subcutaneously before the assessment. An endoscope was passed into the stomach and 180 ml congo red solution washed over the gastric mucosa. Continuing acid production was indicated by the appearance of a black colour (pH < 3) 2 min after introduction of the dye. A grading system was adopted where grades I and II showed little black discoloration and grades III and IV showed increasing areas of discoloration indicating that further denervation was required. All 20 patients undergoing anterior seromyotomy with posterior vagotomy were classified as grade I. Fifteen of an initial 23 patients receiving proximal gastric vagotomy were grade III or IV. Following division of either the right gastroepiploic nerve or the posterior vagal trunk, 22 patients improved to grade I (16) or II (six). In the subsequent five proximal vagotomies, modification of the dissection produced grade I results. Anterior seromyotomy with posterior truncal vagotomy gave consistenly complete vagotomy. The congo red test highlighted major differences in the adequacy of vagotomy achieved using various dissection techniques during proximal gastric vagotomy. The test is a useful, reproducible and simple intraoperative method for assessing the completeness of denervation.

Radical duodenoplasty is the optimum operation in the patients with duodenal peptic ulcers that are complicated with stenosis. Radical duodenoplasty in the patients with ulcer that is cicatrized reduces their stay in the resuscitation's department, reduces the reactive pancreatitis development, makes easier the early postoperative period and decreases of treatment expenses. So, preoperative rehabilitation is necessary in the patients with duodenal peptic ulcers.

Hemipylorectomy with transverse pyloroplasty and vagotomy was made in 922 patients with perforating and bleeding ulcers of pyloric canal. 510 of them had perforation of ulcer, 412--ulcer bleeding. In all the cases ulcer was excised together with anterior semicircle of the pylorus, the defect was sutured transversely. Hemipylorectomy with transverse pyloroplasty was combined with (anterior selective proximal serous-muscular and posterior trunkal) vagotomy. Postoperative lethality in perforation of ulcer was 4.8%, in bleeding--8.2%. From 1 year to 10 years after operation good functional results were achieved in the majority of the patients. This variant of organsaving operation is optimal in complicated ulcers of pyloric canal.

Results of treatment of 751 patients with perforated gastroduodenal ulcers are analyzed. In addition to routine tests, ultrasonography, computed tomography and laparoscopy were used to diagnose difficult cases. The optimum surgical aids are chosen by taking into account the interval between the onset of perforation and admission, a history of peptic ulcerous, the pattern of peritonitis, age, comorbidity, and surgical findings. Organ-saving operations with a vagotomy are preferable. 1% serotonin-adipinate (1 ml dissolved in 200 ml saline solution) was intravenously used to prevent early postvagotomic disorders (gastric atony, dynamic ileus, etc.) in the early postoperative period. Organ-saving operations with vagotomy were found to have some advantage over routine suturing.

The method of surgical treatment of postbulbar ulcers of the duodenum based on the data of their localization, complications, functional state of the stomach and duodenum, technical skills of the surgeon includes radical ablation of the ulcer, reestablishment of the gastroduodenal continuity with the formation of the functionally active anastomosis or selective proximal vagotomy. The method allows to considerably lessen the amount of complications at the early postoperative period and to obtain good functional results at late terms of observations.

Antireflux surgery, highly selective vagotomy (HSV) and Roux-en-Y duodenojejunostomy have been suggested for control of pathophysiological factors involved in patients with Barrett's esophagus (BE). The aim of this study was to evaluate prospectively the results of this technique in patients with complicated (n = 21) and noncomplicated (n=45) BE. Complete evaluation of esophageal function, endoscopic histologic and clinical control was carried out before and 2 years after surgery. Post-operative results show recurrence of ulcer in patients with complicated BE, but no recurrence in patients with non-complicated BE. Preoperative esophageal ulcer and stricture were present in 85.3% and 14.3%, respectively, of patients with complicated BE. In this group, recurrence of these complications was 38.1% and 9.5% respectively. The technique offers excellent results in patients with non-complicated BE. However, in patients with complicated BE, the recurrence rate is higher, mainly because of the persistence of acid reflux into the esophagus.