Bowel Habit After Vagotomy and Gastrojejunostomy
Authors: A. G. Cox, M. R. Bond
Journal: BMJ (1964)

MEMICAL JOU~RNAL ConclusionsThe interim nature of this report must be emphasized.Kiearly no final comprehensive verdict can be reached at this early stage regarding the relative worth of these three opera- tions in the elective treatment of duodenal ulcer, but the following conclusions seem justified.1.Because of the way in which the trial is conducted, the complete absence of operative mortality almost certainly does not accurately reflect the relative hazards of the three operations if used exclusively, but it shows that, with a certain amount of selection, even resection procedures can in the hands of experienced gastrectomists be remarkably safe at the present time.2. There is significantly less nutritional upset after vagotomy and gastro-enterostomy than after subtotal gastrectomy.In its effect on nutrition vagotomy and antrectomy apparently occupies a position midway between these two operations.3. With the exception of early dumping, diarrhoea, and heartburn, most of the common symptoms due to post-operative disturbance of alimentary function occurred with roughly equal frequency after the three operations.Early dumping was encountered a good deal more often after subtotal gastrectomy than after vagotomy and gastro-enterostomy or antrectomy; )verall, the difference was not statistically significant, but if only the moderate and severe grades of the symptoms are considered there is a significant difference.On the other hand, diarrhoea was much more frequent after vagotomy, particularly with 'astro-enterostomy, than after subtotal gastric resection, and this latter difference was significant.It is only fair to add that the number of patients inconvenienced by post-vagotomv diarrhoea, Which was often episodic, very mild, and infrequent, was quite rmall.4. So far the incidence of proved or strongly suspected recurrent ulceration, which has amounted to only 9 instances in the 360 traced cases in the trial and occurred after all three perations, is too small to permit of any deductions concerning the relative effectiveness of the different methods in curing the ulcer diathesis.S. If the overall functional state and general well-being of the patients are assessed by the Visick system of grading, the results of subtotal gastrectomy seem slightly better than in those of either of the other two operations, and especially of vagotomy and gastro-enterostomy, but these differences are not statistically significant.The reason for the greater number of failures after the latter two procedures is not a higher incidence f recurrent ulceration but the more frequent development of symptoms due to alimentary dysfunction, such as bile-vomiting, postprandial epigastric fullness, flatulence, heartburn, and diarrhoea.It would be reasonable to speculate whether fewer troubles of this kind might not have been encountered if pyloroplasty had replaced gastro-enterostomy as the drainage operation, if a Billroth I reconstruction had replaced that of Polya after antrectomy, and if selective vagotomy had been used instead of total abdominal vagotomy as the method of denervation.The merits of these alternative techniques are now under investigation. SummaryProvided no special contraindication existed, such as a very adherent posterior-wall ulcer, cases coming to elective surgery were allotted in random fashion at laparotomy to the three methods under trial.Between 1959 and 1962 360 patients were thus distributed more or less evenly to the trial operations.There were no operative deaths, but 13 subsequent deaths Occurred, unrelated to operation ; two patients were untraced.The results in this study were determined on the latest follow- up findings available on each case, which ranged from one to four years.At follow-up patients were usually interviewed "blindly " by a small panel.Recurrence has been infrequent to date after all three operations, making worth-while comparison impossible.The incidence of most " post-gastrectomy " syndromes was roughly the same after the three operations.But early dumping was significantly more common after subtotal gastrectomy, and diarrhoea (usually mild and episodic) after vagotomy, especially with gastro-enterostomy.Weight loss was significantly greater after subtotal gastrectomy than after vagotomy and gastro-enterostomy; vagotomy and antrectomv occupied an intermediate position in this respect.Grading of the overall results on the Visick scale showed no significant difference in the outcome after the three operations.We should like to express our thanks to the following for their assistance in the conduct of this inquiry: to our surgical colleagues for enduring with such good will the somewhat irksome discipline of a controlled trial ; to Richard Bennett, David Johnston, Andrew Jowett, and James Watts, all members of the staff of the University Department of Surgery, Leeds, for their assiduity and success in tracing a number of patients who had been temporarily lost to follow-up ; to Mr. G. S.