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The overall efficiency of the ff-PYPL is most apparent when we compare our own large series of long-term observations of SPV, accompanied with these pyloroplasty forms with all types of DU, in contrast to the series of SPV without pyloroplasty of some other authors with a smaller number of patients and a shorter observation period (Table 1). The table shows that the combination operation of complete SPV with ff-PYPL (Fig. 17) assures the clinical permanent healing of DU. In GU the results of the nonresecting method are less satisfying. Twenty-two percent of the GU patients must have selective vagotomy with antrectomy because of antral disorder, destroyed antral innervation, or suspicion of malignancy.

Nonresective surgery for gastro-duodenal ulcers (GDU) is the operation of choice in 95% of cases of duodenal ulcer (DU) and approximately 50% of cases of gastric ulcer (GU), with a good probability of permanent success if an adequate selective proximal vagotomy (a-SPV) is combined with a pyloroplasty based on form and function (ff-Py). The result is the elimination of local foci and secretion and motility disturbances.

Unlabelled: In unanesthetized dogs, the mechanical activity of the antrum and pylorus was studied by means of strain gauge force transducers during fasting condition, after feeding, and following application of metoclopramide (Paspertin), before and after SPV without pyloroplasty, and after SPV with pyloroplasty respectively., Results: 1) The mechanical activity during fasting condition differs from that after feeding. 2) During fasting, the contractile force is decreased for about 15%-20% after SPV without pyloroplasty and for about 50% after SPV with pyloroplasty. The frequency remains unchanged. 3) After feeding, the contractile force is decreased by about 50%, the frequency shows an increase of 100%. The same results can be obtained after SPV with or without pyloroplasty. 4) After metoclopramide the contractile force is increased up to 30%, during fasting, after feeding, and also before and after SPV. The frequency, however, shows no significant change. 5) The postoperative findings remained unchanged throughout the entire observation period (up to the 20th postoperative month).

The observations collected on selective proximal vagotomy plus functionally and structurally appropriate pyloroplasty during a period of 13 years have demonstrated that inadequate selective proximal vagotomy results in an excessive rate of relapses and that adequate selective proximal vagotomy without drainage leads to stasis, resulting in retention difficulites or secondary gastric ulcers. In both instances, reoperations are to be expected. If complete healing without resection is what one wishes to accomplish, and who doesn't, adequate selective proximal vagotomy combined with structurally and functionally appropriate pyloroplasty is indicated. This combination can now be considered a reliable standardized procedure of curative nonresection surgical therapy for gastroduodenal ulcers.

Only those patients who were examined endoscopically were evaluated. Concomitant examinations, such as biopsy, histologic studies, roentgenograms, scintiscanning, acid secretion, serum gastrin and review of the operative reports, were done. Duodenal ulcers (1,219) and gastric ulcers (421) were examined preoperatively. Of these, selective proximal vagotomy and pyloroplasty and excision of the ulcer were performed for 1,018 duodenal ulcers. Forty-three per cent were examined postoperatively. Selective proximal vagotomy and pyloroplasty and excision of ulcer were performed for 315 gastric ulcers. Thirty-nine per cent were examined postoperatively. Recurrence was calculated in relation with the patients examined postoperatively. Recurrence of duodenal ulcer occurred in 6.3 per cent; of these, 0.9 per cent had duodenal ulcers develop into gastric ulcers. The recurrence rate of gastric ulcer is 8.1 per cent; of these, 0.8 per cent developed into duodenal ulcers, and 0.8 per cent to carcinoma of the stomach. Data of recurrent ulcers were compared with the data for the total number of patients who underwent surgical treatment. The possible causes for a recurrence are demonstrated. In duodenal ulcers, 79 per cent of recurrences are due to technical error (inadequate vagotomy and incomplete drainage); in gastric ulcers, 90 per cent of recurrences are due to technical error. In both duodenal and gastric ulcers, causes are partly based on advanced clinical symptoms. Recurrence rates showed a tendency to increase between 1969 and 1975 and 1976 and 1983. This correlated directly with the deterioration of the clinical signs and symptoms between 1969 and 1983, shown in increased acid secretion, increase and shift of ulcers and stenoses, increase in bleeding and changed epidemiologic findings.

The effect of selective proximal vagotomy (SpV) with (12 cases) and without (5 cases) pyloroplasty upon basal and food stimulated serum immunoreactive gastrin (IRG) was studied in duodenal ulcer patients. Following SpV, fasting serum IRG increased in all subjects; the increase was more pronounced in subjects whose postoperative insulin tests were negative. Postoperatively, the mean integrated IRG output over 2 hrs in response to a meal was significantly higher than the preoperative mean value in the 17 patients. Pyloroplasty had no effect upon the IRG response following a test meal.