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Highly Selective Vagotomy1

2015; Linguagem: Inglês

10.1159/000398208

2235-4328

David A. Johnston,

Biochemical and Structural Characterization

Progress report Highly selective vagotomyHighly selective vagotomy (HSV) is the first operation for peptic ulcer which both avoids gastric resection and keeps the antral 'mill' and pyloric sphincter intact'.All the standard operations destroy, or at least severely impair, the functions of the antrum and pylorus.Truncal vagotomy with a drainage procedure (TV+ D), once regarded as a conservative operation, has been shown to render the stomach 'incontinent' of liquids2-5, and to produce clinical results which are somewhat inferior to those of vagotomy combined with antrectomy6'7.'Parietal cell vagotomy' (PCV)8, which was introduced in Denmark at the same time as HSV was introduced in Britain, has the same rationale as HSV, but differs from HSV in that the precise extent of the antrum is 'mapped' at the time, of operation.Highly selective vagotomy is a more empirical, but quicker, procedure, which involves the identification and preservation of the main vagal nerves to the antrum, the nerves of Latarjet.A forerunner of both these operations was selective proximal vagotomy (SPV), which also leaves the antrum innervated, but which is invaiiably accompanied by a pyloroplasty or by a limited form of antrec-tomy9.'Proximal gastric vagotomy' has been proposed as a compromise term, but may not be necessary in my opinion, because it will become appar- ent before long whether either a pyloroplasty or antral mapping is required.Even if it is shown, however, that the addition of a pyloroplasty is not necessary, the use of SPV as the standard term would be a suitable tribute to the pioneering work of Holle and Hart in Munich9.What matters to the patient, however, is not the name of the operation, but whether the hypotheses upon which it is based1'9-'1 are correct.These are that the innervated antrum will expel the gastric contents efficiently through an intact pylorus but will not release excessive amounts of gastrin, that side effects such as dumping and diarrhoea will be reduced compared with the incidences which are found after conventional operations, and that recurrent ulceration will be no more frequent than after complete gastric vagotomy with a drainage procedure.It follows from this that any assessment of HSV at present must be incomplete, both because the maximum period of follow up in Leeds and Copenhagen is only five years and because the results of prospective random trials will not be known for many years.However, many of the salient questions have already been answered.The first concerns operative mortality.There has been no operative mortal- ity among 350 patients who have been treated electively for duodenal ulcer by HSV in Leeds and Copenhagen.When these numbers are added to the other series in the literature2-21, a total of over one thousand HSV operations has been reported without an operative death.There has been an isolated case report22, however, of an operative death after HSV, and the author has had one death among 45 patients who were treated by HSV for gastric ulcer.Clearly, HSV is an extremely safe operation, the safety being due, no doubt, to the absence both of a suture line and of an artificial 'loop' such as is