Experimental basis and clinical application of extended highly selective vagotomy for duodenal ulcer

An ideal operation for a benign disease, such as duodenal ulcer, must be effective, relatively free of serious postoperative complications and standardized for effective performance. Highly selective vagotomy, an operation known to have few side effects, has not been adopted by many surgeons because of the concerns about postoperative recurrent ulcers, as well as by concerns about the technical performance of the operation. Recurrent ulcers may be the result of incomplete denervation of the parietal cell mass; based upon the results of intraoperative testing, we suspected that previously unrecognized sites supplied preganglionic vagus nerves to the parietal cell mass. Nerve tracing studies identified four areas in the stomach that are not adequately denervated in the "standard" highly selective vagotomy. Based on these data, we defined and performed "extended highly selective vagotomy" upon 180 patients with ulcers. Herein, the results of follow-up examinations of 113 patients for a mean of at least 4.5 years postoperatively are reported. Recurrent duodenal ulcers occurred in 2.9 percent (two of 69) after extended vagotomy alone, and in none of 44 in whom a drainage procedure was used; the overall recurrence rate was 1.8 percent. Serious postoperative complaints were found in one patient in each group. The use of extended highly selective vagotomy for duodenal ulcer has a rational experimental basis and acceptable clinical results. Pyloroplasty, in conjunction with extended highly selective vagotomy, does not increase the incidence of serious postoperative side effects.