BACKGROUND: The occurrence of postvagotomy complications was initially considered an unavoidable but acceptable consequence of duodenal ulcer surgery. Following the description of ''selective'' vagotomy procedures, however, it became apparent that effective ulcer surgery might be accomplished without unpleasant sequellae.METHODS: In 1957 the experimental basis for ''highly'' selective vagotomy (HSV), which preserved antral innervation, was reported. HSV was performed in several European centers between 1960 and 1968, and was widely accepted there. Surgeons in the United States, in contrast, were largely reluctant to use HSV, an operation which had an excessive ulcer recurrence rate compared to vagotomy-antrectomy. More recently, HSV is recognized as a successful operation, due to more complete division of preganglionic gastric vagal nerves (''extended'' HSV) and the liberal use of pyloric reconstruction in patients with juxtapyloric ulcers.RESULTS: HSV is performed with minimal morbidity, with an incidence of recurrent ulcer which is less than 5%. Complications such as dumping, diarrhea, and gastric atony are quite rare.CONCLUSIONS: HSV is an ideal procedure for most patients with duodenal ulcer. Because most operations for ulcer are performed for urgent or life-threatening problems, the most common operation performed in the United States today is truncal vagotomy combined with pyloroplasty or gastric resection. Earlier operation for chronic ulcer has many potential advantages.

In 178 patients undergoing elective cholecystectomy for biliary colic, the papilla was calibrated with a no. 10 French catheter through the cystic duct. The catheter passed through the papilla into the duodenum in 94 patients. Six (6 percent) had common duct stones. No postcholecystectomy colic occurred. In 37 patients the catheter was obstructed by papillary stenosis and sphincteroplasty was done. Common duct stones occurred in 17 patients (46 percent), jaundice in 7 and dilatation of the common duct in 6. Cholangiograms failed to detect small stones in seven patients and were of minimal value in positively identifying stenosis. In 49 control patients the papilla was not calibrated. Cholangiograms were normal. Postcholecystectomy colic occurred in seven patients, two of whom underwent subsequent sphincteroplasty. It is concluded that calibration is a worthwhile adjunct to cholangiography. Sphincteroplasty permits passage of small stones that may not be apparent on Cholangiograms and are retained by papillary stenosis, and prevents colic (dyskinesia) of stenosis that also may not be apparent on cholangiograms.

The chairman began the discussion by reviewing the various types of intraoperative tests. These tests included leucomethylene blue, Grassi, Burge, and Kusakari, According to Harrison, whose unit performed special studies on the leucomethylene blue test, it is not of great value.

Among an initial series of 103 patients with selective vagotomy plus pyloroplasty for duodenal ulcer, 9 patients died of causes unrelated to ulcer and 7 were lost to follow-up without signs or symptoms of ulcer 8 to 15 years after operation; the remaining 87 patients were followed up for 12 to 17 years. Insulin testing revealed only one inadequate vagotomy in a patient who had a recurrence in the short term. Insulin tests were negative in 61 and negative or adequate in 6 other patients. Complete vagotomy reduced basal secretion effectively in the great majority of patients but not in a small minority. Three patients had antral hyperfunction with persistent hypersecretion despite complete vagotomy as indicated by two negative insulin tests in each patient. Inexplicably, only one of these patients had a stomal ulcer recurrence.

Surgical trainees often question the fact that different repairs are recommended for the single entity of indirect inguinal hernia, and ask which is the best repair and why. The purpose of this review is to answer these questions with fundamental anatomic, physiologic, and surgical concepts.

Everett, M. T. M.B., B.S., F.R.C.S.; Griffith, Charles A. M.D., M.Sc., F.A.C.S. Author Information

JONES, WYN M. F.R.C.S., (E.), F.R.C.S. (G.); GRIFFITH, CHARLES A. M. D., M. Sc., F.A.C.S. Author Information

Hepatic and celiac vagotomy in dogs does not alter the volume and motility of the gallbladder after 10 weeks. However, hepatic and celiac vagotomy results in less secretion of bilirubin and neutral red in bile and decreased concentration of radiologic contrast material in the gallbladder.

Amdrup, B. M. & Griffith, C. A. 1970. The Effect of Insulin upon the Secretory Response to Feeding in Dogs with Selective Vagotomy of the Parietal Cell Mass. Scand. J. Gastroent. 5, 655-665.The study concerns Heidenhain pouch dogs which had undergone selective vagotomy of the parietal cell mass or selective vagotomy plus suprapyloric antrectomy. Other dogs which had undergone appropriate operations were used as comparative controls. Feeding responses alone, and feeding responses in the presence of insulin hypoglycaemia were compared. In the selective vagotomy dogs insulin stimulation of acid secretion was preceded by inhibition. Insulin’s stimulatory effect was reduced in dogs with additional suprapyloric antrectomy. Results suggest that the gastric vagi may sensitise the antral gastrin producing apparatus. Extragastric vagi may in some way inhibit gastric secretion.

Amdrup, B. M. & Griffith, C. A. 1970. The Effect of a Ganglion-blocking Agent (Hexamethonium Bromide) upon the Secretory Response to Feeding in Dogs with Selective Vagotomy of the Parietal Cell Mass. Scand. J. Gastroent. 5, 667-674.Feeding response in Heidenhain pouch dogs with selective vagotomy of the parietal cell mass with and without suprapyloric antrectomy was compared to feeding response during treatment with hexamethonium bromide. The effect of hexamethonium was initial inhibiton of pouch secretion, followed by delayed hypersecretion. The inhibition may result from blockage of vagal stimulation of the antrum. The reason for the delayed hypersecretion is discussed.

The findings of the gross anatomical dissections indicate that the abdominal vagal system in rats is similar to that in dogs and man: 2 trunks (one anterior and one posterior) and 4 truncal divisions (hepatic, celiac, and anterior and posterior gastric divisions). The findings with neutral red indicate that the distribution of the gastric vagi to the stomach in rats is the same as that in dogs: a segmental distribution in which the anterior and posterior gastric divisions innervate the anterior and posterior walls of the stomach, respectively, and the terminal branches from the anterior and posterior gastric divisions innervate separate segments of the anterior and posterior walls of the stomach. These anatomical similarities in rats, dogs, and man lend further support to the use of rats as acceptable experimental animals for studies of the vagal phase of gastric secretion.

From the Department of Surgery, University of Washington School of Medicine, Seattle, Washington 98105 *Visiting Scientist, on leave from the Department of Surgery, Frederiksberg Hospital, Copenhagen, Denmark. **Clinical Associate Professor of Surgery.

Shilna, Ehchi M.D. Dr. of Med. Sci*; Griffith, Charles A. M.D., M.Sc., F.A.C.S.** Author Information

Why should the duodenal mucosa in a minority of individuals be susceptible to the digestive action of gastric juice whereas in the majority it possesses a remarkable resistance ? Many have sought the answer to this question believing that therein lay the solution to the peptic ulcer problem. Even to-day, our armamentarium strengthened by many new research tools and techniques, the explanation of the variable vulnerability of the duodenal mucosa evades us. By contrast knowledge of the physiology of gastric secretion has increased, modestly in relation to the pepsin moiety, considerably in relation to the acid moiety. And so, at the present time, the surgical management of duodenal ulcer has as its physiological basis the control of gastric acid secretion; an appreciation of the intricate mechanisms involved in acid production and of the effects of surgical operations on these mechanisms is desirable.

This report is prompted by two questions. Are all sequelae of total vagotomy plus complementary drainage or antrectomy due to the effects of vagotomy and drainage of the stomach or are some sequelae due to the effects of eliminating the function of the hepatic and celiac vagi? If the latter is the case, are any of the sequelae significant enough to warrant their prevention by preserving the hepatic and celiac vagi with selective vagotomy? Most investigations have approached these questions from the standpoint of digestion, absorption, diarrhea, and over-all nutrition. The results indicate little if any superiority of selective vagotomy over total vagotomy on this basis, and there is now general agreement that the secretory functions of the hepatic and celiac vagi affecting the output of pancreatic juice, bile, and succus entericus are clinically insignificant. The purpose of this report is to answer these questions with clinical and experimental evidence indicating that the hepatic and celiac vagi have other significant functions. These functions concern motility of the gallbladder and intestine pertinent to the sequelae of biliary sludge and gallstones, severe postoperative ileus of the midgut, and long-term intestinal dysfunction after total vagotomy. In addition, experimental studies have elucidated the existence of a heretofore unknown function, namely, inhibition of gastric acid secretion by the hepatic and celiac vagi. This inhibitory function seems significant enough to be a factor in the sequelae of recurrent ulcer and, as