Vagotomy and Pyloroplasty: Advances 1975–1980

146 Pages·1980·13.52 MB·English

by  Dr. Fritz Holle

Vagotomy
and Pyloroplasty
Advances 1975-1980
The non-resective method (adequate selective proxi
mal vagotomy -"a-spv"- combined with pyloroplasty
appropriate to form and function -"ff-pypl"-) as a
means of operative treatment of peptic ulcer disease
and other benign disorders of the stomach
Edited by F. Holle and G .E. Holle
With 113 Figures (31 Figures in Color) and 27 Tables
Springer- Ve riag
Berlin Heidelberg N ew York 1980
Dr. Fritz Holle
o. Professor der Chirurgie, F.A.C.S. (hon.)
gf. Oirektor der Poliklinik der Universitiit Miinchen
Oirektor der Chirurg. Poliklinik der Universitiit
0-8000 Miinchen 2, Pettenkoferstr. 8a
Dr. med. Gertrud Elisabeth Holle
0-8000 Miinchen 90, Lindenstr. 7
ISBN -13 :978-3-540-10083-6 e-ISBN -13:978-3-642-67652-9
DOl: 10.1007/978-3-642-67652-9
Library of Congress Cataloging in Publication Data.
Main entry uoder title:
Vagotomy and Pyloroplasty advances 1975-1980
Supplement to Vagotomy, edited by F. Holle and S. Anderson.
Bibliography: p.lncludes index. I. Vagus nerve-Surgery. 2. Peptic ulcer-Surgery.!. Holle,
Fritz, 1914-II. Holle, Gertrud E. III. Aigner, R. lV. Holle, Fritz, 1914-Vagotomy. [DNLM:
1. Peptic ulcer-Surgery. 2. Vagotomy. W1350 V126 1974 Supp1. 1975-80] RD540.57.H632
617'.48380-16048.
ISBN-13:978-3-S40-10083-6 (U.S.)
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© Springer-Verlag Berlin Heidelberg 1980
The use of registered names, trademarks etc. in this publication does not imply even
in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
Typesetting: Fotosatz Weihrauch, Wiirzburg
2124/3321-543210
To those who suffer from stomach disorders
to my clinical teacher
Prof. Dr. Dr. hc. W. Wachsmuth
to our good friends and colleagues allover the world
Preface
The preceding monograph: ''Vagotomy - latest advances",
Springer-Verlag, 1974 ed. by F. Holle and S. Andersson reported
an innovation in surgery: the so-called "selective proximal vago
tomy (spv) with pyloroplasty (pypl)". The usefulness of the
method was put to the test in cases of peptic ulcer disease and in
dog experiments. No claim was made - as some reviewers
erroneously supposed - that the method was a comprehensive
presentation of the surgery of peptic ulcer disease or even that it
offered a patent solution to this subject Instead, it should be
regarded as the initial step towards this goal. The clinical results
obtained during the years 1964-74 encouraged us to pursue this
line of approach with a view of reaching a stomachpreserving or
non-resective method in peptic ulcer surgery and to test the appli
cability of the method to other benign disorders of the stomach.
After 16 years of testing and experience with over 2000 cases
(Dec. 1St. 1979) of selective proximal vagotomy with pyloroplasty,
supplemented by advanced studies on the pathophysiology of the
method, an additional volume is now proposed: "Vagotomy and
Pyloroplasty, advances 1975-1980", Springer-Verlag 1980. This
subsequent volume deals primarily with improvements and
findings made during the last 5 years. It also refers to important
questions concerning the practical performance of the method
which arose from congresses and discussions in this field.
These are:
1. Definition, efficiency and effects of the model: spv + pypl.
2. Prerequisites of an adequate spv (a-spv)
3. Functional indication and choice of procedure for an a-spv.
4. Functional diagnostics of the stomach as a whole.
5. Standard technique of an a-spv.
6. Disadvantages of an a-spv - the why? and how? of a pyloro
plasty.
7. Importance of the antro-pyloric area for pyloroplasty.
8. Standard technique of pyloroplasty appropriate to form and
function
9. Long-term and comparative results of the non-resective
operative treatment of primary peptic ulcer disease.
VIII Preface
10. Indication, application and results of the method in other
benign disorders of the stomach.
Further progress can be shown with regard to the certainty of
the indication and the likelihood of a permanent cure for the
patient.
In spite of this progress it must be emphasized that there are
still questions open to discussion or which even impose limits on
the method. Some questions in particular must be investigated by
controlled studies. Such studies are dealt with in our clinic and are
very time-consuming. Publication must be postponed until all
suppositions have been reduced to possibilities. Only then will it
be profitable to begin controlled studies within the relevant terms
of reference.
It is therefore likely that this present volume will be followed
by others until the whole complex has been resolved.
Sincere thanks are given to Dr. Dres. h.c. Heinz G6tze of
Springer-Verlag for undertaking to publish a second volume in
this series and for the excellent presentation. Grateful ack
nowledgements are also due to Herrn Rupprecht of Springer
Verlag for his detailed editing, to Frl. I. Daxwanger for the half
tone photographs, to Herrn N iissl for the diagrams, and to all those
who have contributed in any way to the realization of the method.
Finally we are due to the "Deutsche Forschungsgemeinschaft"
for granting (HO 86119) the volume.
Munich, March 1980 The Editors
Contents
l
List of Contributors . . . . . . . . . . . . . XIII
Part A: Introduction
I. Mechanical Versus Functional Surgery 3
II. The Beginning of Functional Surgery for Peptic Ulcer 4
III. Early Observations on a Functional Method of Surgical
Treatment for Peptic Ulcer. . • . . • • . • .. 6
IV. Establishment of Theoretical Model of a Non-resective .
Method . . . . . . . . . . . . . 8
Part B: Patho-physiological Background
I. Definition and Efficiency of the Model 13
1. Parameters for Checking the Model 13
2. Designation of the Model 13
3. Efficiency of the Model. . 14
II. Effects of the Model . . . 15
1. Effect on Gastric Secretion . 15
2. Long-term Effect on Acid Secretion (H. Bauer) 18
3. Explanation of the Acid-reducing Effect 20
4. Histological Effect on the Fundic Mucosa (G.E. Holle) . 21
5. Effect on Blood Circulation (1. Lenz) 29
6. Effect on Gastrin Release (H. Bauer) . . . . . . 30
7. Findings still Open to Question 30
Part C: Prerequisites and Technique of Adequate
SPY (= a-SPY)
I. Prerequisites for an a-SPV . . . . . . . . 33.
1. Suitable Tests for a Critical Examination of a-SPY 33
2. Technique Which is Both Effective and Durable . 35
I Where no author is named the chapter is worked out by F. Holle
x Contents
3. Topographical and Practical Anatomy 35
4. Importance of the "Borderline Nerves" 38
5. Importance of intra-operative Tests . 39
II. Functional Considerations Regarding Indication and
Choice of Procedure. . . . . . . . . . 40
1. Procedures Appropriate to Form and Function 40
2. Practical Model for Non-resective Procedure . 42
3. Functional "Key" to Procedure . . . . . 43
4. Diagnostic System Ensuring Reliable Indication 44
5. Choice of Functional Procedure . . . . . 45
III. Standard Technique of Adequate SPV (a-SPV) 51
Part D: The Why? and How? of Drainage Within
the Non-resective Method
I. The Deficiencies of a-SPV . 59
1. Effect on Acid Secretion and Gastrin Release After
Feeding (H. Bauer) . . . . . . . . . . . . . 59
2. Effect on Gastric Motility . . . . . . . . . . 61
3. Motility After Step-wise Denervation of the Antrum
(W. Heltzel) . . . . . . . . . . . . . . . 62
4. Influence of Motility on the Pathogenesis of Gastric
Ulcer (Dragstedt's Theory) (0. Hellerer, R. Aigner) 64
II. The Importance of the Antro-pyloric Canal. . . . . 66
1. Significance of Neural and Muscle Coat Changes in
the Antro-pyloric Aerea (0. Hellerer, O. Stochdorph,
R. Aigner) . . . . . . . . . . . . 66
2. Diagnostic Value of Gastrin Measurement. 68
3. The Gastrin Profile Test (H. Bauer) . . . 70
4. Resume of Part D I., II., 1-3 . . . . . 71
5. Significance of the Corpus-antrum Transitional Zone for
Acid Reduction (H. Bauer) . . . . . . . . . . 72
III. Functional Measurement of the Motility of the Stomach
as a Whole (Especially Functional Scintigraphy). . . . 74
1. Gastro-duodenal Scintigraphy (B. Leisner, W.L. Brueck-
ner) . . . . . . . . . . . . . . . .. 74
2. Comparison of X-ray and Scintigraphic Evaluation (B.
Leisner, J. Lissner) . . . . . . . . . . .. 77
3 .. Esophago-gastric Scintigraphy (especially in Hiatal
Hernia and Achalasia) (W.L. Brueckner, B. Leisner) 80
Contents XI
IV. The Meaning of Pyloroplasty appropriate to Form and
Function (ff-pypl) and its Standard Techniques 85
1. Submucosal (s.m.) Pyloroplasty 85
2. Open Pyloroplasty. . . . . . . . . 86
3. Pylorectomy. . . . . . . . . . . 92
4. Retrocolic Posterior Gastro-enterostomy as a Way
Out . . . . . . . . . . . . . . . 92
Part E: Results: Short Review of Experiences with
the Non-resective Method in 2072 Cases
I. Clinical and Experimental Examinations on the Efficiency
ofa ff-Pyloroplasty . . . . . . . . . . . . . 97
II. Effect of Different Pyloroplasties on Functional Re-
sults (H. Bauer) . . . . . . . . . . . . . . 99
III. Clinical Results of the Munich Series Compared to Other
Studies (H. Bauer) . . . . . . . . . . . . . 101
IV. Summary of Present Non-resective Surgery for Primary
Peptic Ulcer. . . . . . . . . . . . . . . . 105
Part F: Indication, Application and Results of the
Method in Cases Other Than Primary Peptic
Ulcer
I. Complicated Ulcer. . . 109
1. Perforated Ulcer . . . 109
2. Bleeding Ulcer (H. Bauer) 109
3. Functional Indication and Choice of Procedure in
Recurrent Ulcer (H. Bauer) . . . . . . . . . . 110
II. Achalasia, Hiatal Hernia and other Indications 119
1. Method in Achalasia of Cardia (W.L. Brueckner,
B. Leisner) . . . . . . . . . . . . . . . . 119
2. Method in Hiatal Hernia (W.L. Brueckner, B. Leisner). 122
3. Other Indications Under Discussion (Hypersecretion,
Dyspepsia, Gastritis, Prophylactic Application) . .. 125
III. Appendix . . . . . . . . . . . . . . . 126
1. Indication in Cases of Concomitant Psycho syndrome . 126
2. How to Advise the Patient on His Post-operative Way
of Life (Leaflet) 127
References . 129
Subject Index . 139
List of Contributors
Dr. med. vet Reinhard Aigner Dr. med. Gertrud E. Holle
Anatomische Anstalt Chirurgische Univ.-Poliklinik
Pettenkoferstr. 11 Pettenkoferstr. 8a
8000 Miinchen 2 8000 Miinchen 2
Prof. Dr. med. Hartwig Bauer Dr. med. Bernhard Leisner
Chirurgische Univ.-Poliklinik Klinik und Poliklinik fUr Radiologie
Pettenkoferstr. 8a der Universimt Miinchen
8000 Miinchen 2 Ziemssenstr. 1,8000 Miinchen 2
Priv.-Doz. Dr. Jiirgen Lenz
Prof. Dr. med. Walter L. Bruckner
Chirurgische Abteilung des
Chirurgische Univ.-Poliklinik
Bundeswehrzentralkrankenhauses
Pettenkoferstr. 8a
Riibenacher Str. 170, 5400 Koblenz·
8000 Miinchen 2
Prof. Dr. med. Josef Lissner
Dr. med. Oskar Hellerer
Klinik und Poliklinik flir Radiologie
Chirurgische Univ.-Poliklinik
der Universimt Miinchen
Pettenkoferstr. 8a
Ziemssenstr. 1, 8000 Miinchen 2
8000 Miinchen 2
Dr. med. Silvano Reiser
Dr. med. Wilfried Heltzel
Chirurgische Univ.-Poliklinik
Chirurgische Univ.-Poliklinik
Pettenkoferstr. 8a
Pettenkoferstr. 8a
8000 Miinchen 2
8000 Miinchen 2
Prof. Dr. med. Otto Stochdorph
Prof. Dr. med. Fritz Karl Holle Institut fUr Neuropathologie
Chirurgische Univ.-Poliklinik der Universimt Miinchen
Pettenkoferstr. 8a Thalkirchner Str. 36
8000 Miinchen 2 8000 Miinchen 2