laparoscopic anterior seromyotomy with posterior truncal vagotomy ...

List ofImages
Image
Image 1: ECRT showing black color change during PGV -----------------­
Image 2: ERCT showing disappearance ofthe black color -----------------­
Image 3: Large deep active DU ------------------------------------------------­
Image 4: Deformed duodenal cap ----------------------------------------------­
Image 5: Elevation ofthe liver -------------------------------------------------­
Image 6: Opening the lesser omentum ----------------------------------------­
Image 7: The two landmarks for posterior truncal vagotomy --------------­
Image 8: Traction of the white posterior vagus trunk -----------------------­
Image 9: Clipping the posterior vagus trunk ---------------------------------­
Image 10: A segment ofthe posterior vagus trunk resected ----------------­
Image 11: Ligation ofthe big vessels onto the stomach ---------------------­
Image 12: Marking the line of anterior seromyotomy ---------------------.-­
Image 13: The esophagogastric junction --------------------------------------­
Image 14: The crew's foot ------------------------------------------.-----------­
Image 15: Starting seromyotorny from below ---------.------.---------------­
Image 16: Seromyotomy using bipolar coagulating knife --------.---------­
Image 17: Seromyotomy using coagulating hook ----------------------------­
Image 18: Suturing seromyotomy -------------.--------------------------------­
Image 19: Chronic DU by intraoperative ECRT .-------------.--------------­
Image 20: Gastric outlet patency by intraoperative ECRT ------------------­
Image 21: Washing gastric ----------.-------------------------------------------­
Image 22: Spraying gastric mucosa with CR ---------------------------------­
Image 23: Gastric mucosa at the end of ECRT -----------------.--------------
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ACKNOWLEDGEMENT
First ofall I offer my great thankful prayer to Allah
I wish to express my great thanks to my kind professor, Prof. Dr.
Mohammad Abd AI-Bary Al-Sharabasy, Prof Dr. of general surgery, Faculty
of Medicine, Zagazig University, for his great patiency, kind advises and help.
And, I wish to express my great thanks to my kind professor, Prof. Dr.
Ismaiel Abd AI-Rahman Koutb, Prof Dr. of general surgery, Faculty of
Medicine, Zagazig University, for his great faithful sympathy and help.
Also, I wish to express my great thanks to my kind professor, Prof. Dr.
Nabiel Ali Gad AI-Hak, Prof Dr. of general surgery, Faculty of Medicine,
Mansoura University, for his great advises and encouraging help.
To, Dr. Samir Ibrahim Mohammad, Lecturer of general surgery, Faculty
of Medicine, Zagazig University, I express many thanks and gratitude for his
great cooperation in doing the intraoperative endoscopic Congo red test.
Dr. Samy Shahwan

With LOVE!
DEDICATION
To the soul ofmy MOTHER,
To my FATHER,
To my WIFE,
I dedicate this work.
To my SONS & DAUGHTERS,
To ALL WHO LOVED ME &
To ALL WHO HELPED ME;
Dr. Samy Shahwan
,"

-2-
increasingly encountering treatment 'failures. In a recent survey, United
States physicians reported using 103 different eradication regimens; many
were ineffective or ofunknown effectiveness (Freston, 2000).
The era ofHi-receptor blocker treatment for peptic ulcer disease had
already led to a sharp decline in the elective treatment of such disease.
Yet, during era there did not appear to be any fall in the rates of peptic
ulcer perforation. This seems surprising and means that we can not
assume on a priori grounds alone that the rate of perforation will fall
during the H. pylori era (Jamieson, 2000).
The side effects ofantibiotic therapy can include digestive problems
in 30% of patients, especially pseudomembranous colitis, that oblige
patients to stop therapy (Mouiel et al., 1999).
Medical therapy cures in just a few weeks over 95% of patients;
however, when suspended, the rate of relapses varies from 10% after ]
month's therapy to 65% after 18 months (Croce et aI., 1999). Once
medication is stopped, however, ulcer recurrence is frequent, hence the
need for maintenance treatment (Mouiel et al., 1999).
The relation between H. pylori infection and gastroesophageal reflux
disease (GERD), once thought to be non existent, has become a clinically
relevant issue in light of reports suggesting that the presence ofH. pylori
infection may in some way afford some protection against the
development of GERD. Evidence suggests that H. pylori eradication may
foster the development oferosive esophagitis (Freston, 2000).
H. pylori eradication in duodenal ulcer patients was followed by a
significant increase in the prevalence of erosive esophagitis after 3 years
"-ro:

-4-
with medical treatments for this benign, frequent and recurrent disease is
often far from satisfactory (Mouie! et al., I 999).
Yet, ulcer-related mortality remains a serious health problem, and its
incidence has even risen in the elderly, surgical treatment, with its
recognized long-term efficacy, may thus have a role to play in the
prevention ofcomplications (Meuiel et aI., 1999).
Despite this enormous success of medical therapy, there are several
reasons why elective surgery for peptic ulcer disease is unlikely to
disappear altogether. First is the fact that medical treatment still
sometimes, fails, in such patients anti-ulcer surgery remains an
appropriate option-more so since the advent of laparoscopic highly
selective vagotomy. Second is the cost of treatment, particularly when
that treatment is centered on anti-secretory drugs. This means that in less
economically developed countries, elective laparoscopic anti-ulcer
surgery is likely to continue and may even flourish (Jamieson, 2000).
A parameter to be taken into account is the patient preference, i.e.
the duly informed patient can select either prolonged medical therapy or
minimally invasive surgical procedure (Mouiel et al., 1999).
It must be noted that the percentage of operations being carried out
in patients with peptic ulcer disease has sharply increased in regard to
emergency surgery and there is no doubt that a large part of this increase
has been due to the decrease in elective surgery (Jamieson, 2000).
Regarding highly selective vagotomy, there are, however, several
drawbacks: the operative technique is difficult, and training is required to
successfully complete proximal denervation of the distal esophagus and
distal denervation of the upper part ofthe crow's foot There is also a risk
t 'or'

-6-
denervation ofthe pancreas and the intestine. In particular, post-vagotomy
diarrhea is avoided and motility is maintained in the pyloric and antral
regions. Similarly, anterior seromyotomy spares the pyloric branches of
the vagus nerves, thereby preserving the antral pump and preventing
pylorospasm. This in tum ensures physiological emptying to the stomach,
obviating the need for an associated drainage procedure. The procedure
combines the rapidity and effectiveness of truncal vagotomy, which has
the advantage of maintaining the gastric antral pump; with ultraselective
vagotomy (Mouiel et aI., 1999).
An advantage of anterior seromyotomy with posterior truncal
vagotomy over PGV is a shorter operating time, Seromyotomy with
posterior vagotomy also appeared to give a more consistent and effective
vagotomy than PGV (Chisholm er al., 1993).
In the last 5 years, laparoscopic techniques have been reported for
the management of uncompiicated peptic ulcer disease, including
laparoscopic truncal vagotomy, proximal gastric vagotomy, and anterior
seromyotomy with posterior truncal vagotomy (Kollmorgen et al., 1996).
This minimally invasive surgical approach has opened a new era in
effective treatment of ulcer disease and from now on must represent an
alternative to long-term medical therapy. The technique also has other
undeniable technical advantages, which have been confirmed by other
investigators: the procedure is easier, faster to perform, and gives constant
results, even in obese patients, because the success of the operation is
independent of anatomic variations in the vagus nerve (Mouiel et aI.,
1999),

-7-
However, if the same physiologic consequences can be obtained
with less pain, shorter hospital stay, and faster recovery, the advantages
ofa laparoscopic approach are obvious (Kollmorgen et al., 1996).
To conclude, the advent of laparoscopy has made it possible, not
only to surgically correct peptic diseases non-traumatically by reducing
the complications of this pathology and releasing patients from the need
for chronic medical therapy, but also to obtain functional results which
can be overlapped with the traditional surgical ones (Croce et al., 1999).
An approach to ensuring adequate vagotomy is to perform intra­
operative intra-gastric pressure monitoring or pH testing (Chisholm et al.,
1993). An endoscopic test that uses Congo red as an indicator of acid
production during PGV is recently modified. (Donahue et al.,(1987).

-8-
AIl"d OF THE WORK
This study aims at evaluation of the results of laparoscopic anterior
seromyotomy with posterior truncal vagotomy as a surgical treatment for
chronic duodenal ulcer disease.

Surgical Anatomy:
-9-
REVIEW OF LITERATURE
• Mucosa.
• Musculature.
• Arteries.
• Nerve supply.
SurgicalPhysiology.
ChronicDuodenalUlcer Disease:
• Definition.
• Incidence.
• Location.
• Aetiology.
• Pathologyand pathogenesis.
• Clinical picture.
• Diagnosis and investigations.
• Complications.
• Treatment ofchronic duodenal ulcer-

MUCOSA:
-10-
SURGICAL ANATOMY
The stomach is divided into the traditional bJTOSS anatomic areas.
However, if we define fundus as the stomach's dome, or that part above
the esophageal inlet, and define pylorus as the part at the pyloric
sphincter, then the fundus and pylorus are the only parts of the stomach
we can accurately delineate by gross examination. We can not accurately
delineate the cardia, corpus and antrum, because the stomach's gross
configuration does not present any landmarks that allow to do so (Figure
l.A). The incisura angularis ventriculi on the lesser curvature separates
corpus from antrum in textbooks and in the dissecting laboratory but, in
the operating room, this landmark either cannot be found or can be only
vaguely located. Furthermore, the incisura angularis ventriculi may often
be confused with peristaltic waves on radiographs. Even when an
incisura angularis is thought to be identified, its position changes from
an erect to a horizontal position (Griffith, 1995).

Mucosal Typt"S:
-11-
Older histologic terminology is both confusing and surgically
meaningless. To impart more surgical meaning, the four distinct types of
mucosa in the adult foregut are divided as follows (Fig. 1-8):
1. Stratified squamous epithelium lines the esophagus. Mucous cells
underliethe most distal esophageal epithelium.
2. Parietal mucosa, which Kay of Glasgow first called the parietal
cell mass and others the oxyntic mucosa, contains the parietal
and chief cells that secrete acid and pepsin, respectively.
3. Antral mucosa contains mucous cells and the G cells that secrete
gastrin. Chief and parietal cells are scarce to absent. In contrast to
the acid surface of the parietal II1UCOSa, the surface of the antral
mucosa is neutral or slightlyalkaline.
4 Duodenal mucosa is characterized by the presence of Brunner
glands, which always extend distally as far as the papilla of Vater
and, in most bodies, beyond the papilla but never as far as the
jejunum. The alkaline mucus secreted by Brunner glands provides
the proximal duodenum with more resistance to acid-peptic
ulceration than jejunum (Griffith, 1995).

Mucosal Resistance and Ulceration:
-13-
The esophageal squamous epithelium is the least resistant to acid­
pepsin ulceration of the four mucosal types. Following; in order of
increasing resistance, are the duodenal mucosa, the antral mucosa and
the parietal mucosa. Because parietal mucosa is the most resistant to
acid-peptic ulceration, gastric ulcer is rare. Careful histologic studies
have shown that gastric ulcers in the parietal area occur either in ectopic
islands of antral mucosa within the parietal mucosa or in parietal mucosa
that has become "intestinalized" or "antralized" by injury from duodenal
reflux (Capper et al,1966). The surfaces of both the ectopic islands of
antral mucosa and the antralized parietal mucosa are neutral or alkaline
(Oi et at, 1969).
Mucosal Junctions:
1. Mucosal Esophagogastric Junction:
The mucosal esophagogastric junction is readily seen as a sharp
line on the gross mucosal surface. Microscopical sections through this
junction reveal an abrupt transition from stratified squamous epithelium
to gastric mucosa, with mucous glands underlying both types of
epithelium (Griffith, 1995).

2_ Antral-Parietal Mucosal Junction:
-14-
No gross anatomic landmarks exist to locate the antral-parietal
mucosal border. However, the border usually lies in the general area
where the rugal folds of the corpus flatten out onto the smooth surface of
the antrom(Landboe,1944). Microscopical sections reveal that the
parietal mucosa gives way to the antral mucosa either abruptly or
gradually in a zone of transition that rarely exceeds 1cm. The antral­
parietal border can also be clearly demonstrated by topical Congo red
(CR) or intravenous neutral red. The distance from this border to the
pylorus varies considerably (Pritchard et 81.,1968).
3.Mucosal Gastroduodenal Junction:
The mucosal gastroduodenal junction usually is within the pyloric
sphincter but may be either immediately proximal or immediately distal
to it. Although the gastroduodenal junction may be seen, on close
inspection, to be a straight or dentate line, this junction is not nearly so
obvious as the gross esophagogastric junction. However, microscopical
sections always reveal a sharp transition from antral to duodenal mucosa
(Oi et aI., 1959)_
--rl.

Surgical Applications:
-15-
1. Mucosal Junctions and Peptic Ulcer:
Oi et al (1959) showed that ulcers occur adjacent to mucosal
junctions. Reflux esophagitis and ulceration are most severe immediately
proximal to the esophagogastric junction. With the unusual exception of
postbulbar ulcer, duodenal ulcers occur just distal to the gastroduodenal
junction. Gastric ulcers most commonly occur immediately distal to
either the antral-parietal mucosal junction or the antralized parietal­
mucosal junction. Thus, peptic ulcers occur at or adjacent to junctions
where the pH of the mucosal surface changes and always on the alkaline
side ofthe junction (Capper, 1967).
2. PYloric Ulcer:
- Duodenal or Gastric ?'
The antral-duodenal mucosal junction usually lies within the
pyloric channel but may lie proximal or distal to it. Thus, dependent on
the specific variation present, a given channel ulcer may be either
duodenal or gastric. This histologic differentiation mayor may not
explainthe unique intractabilityofpyloric ulcer (Griffith, 1995).

3. Prepyloric Duodenal Ulcer:
-16-
In the unusual to rare patient the antral-duodenal mucosal border
lies as far as 2cm proximal to the pylorus. In these patients, a prepyloric
ulcer may therefore be duodenal rather than gastric (Landboe, 1944).
4. High and Low Gastric Ulcers:
The usual location of the antral-parietal mucosal border in the
distal part of the middle third of the stomach explains the usual location
of gastric ulcers. However, the location of the antral-parietal border
varies considerably. When located in the proximal third of the stomach,
accompanied by antralization of the parietal mucosa, the ulcer is high in
the unusual to rare instance, as high as the cardia. In contrast, when the
antral-parietal border is low, the ulcer is prepyloric (or, in Oi's (1959)
terminology, juxtapyloric). Prepyloric ulcers are much more commonly
gastric than duodenal (Griffith, 1995)
S. The Antral Cell Mass:
In most patients with gasstric ulcer and in patients without ulcer but
with dyspepsia of gastritis due to duodenal reflux through an

-18-
oblique muscle and proximal to the circular muscle bundleTurtbermore,
gastric ulcers occur most commonly when the circular muscle border
underlies the antral-parietal mucosal border. When these two borders arc
not in proximity to each other, gastric ulcer is rare but gastritis is not
Thus, Oi et aL(1969) entitled their work "A possible dual control
mechanism in the origin of peptic ulcer"; the paper proposes the theses
of mucosal sensitivity and the kinetic strain of musculature activity. This
dual control also influences the formation of duodenal ulcer just distal to
the pylorus. The pyloric sphincter consists of a thickening of the middle
circular muscle; with the rare exceptions previously described, this
sphincteric border underlies the antral-duodenal mucosal border
(Griffith, 1995)
Pylorus:
When the pylorus was not readily located because of edema or
fibrosis, its identification would be described by a vein that is highly
constant and has been called the pyloric vein of Mayo (Mayo,1907). The
middle circular muscle thickens gradually to form the pyloric sphincter.
This thickening ends abruptly on the duodenal side. Also, the circular

-19-
muscle fibers of the pyloric sphincter converge on the lesser curvature to
form a torus (Torgensen, 1942).
ARTERIES:
1.Submucosal plexus:
The stomach receives its blood supply through its two mesenteric
borders (the lesser and greater curvatures) (Fig. 2). The right and left
gastric arteries run within the lesser omentum adjacent to the lesser
curvature, and the right and left gastroepiploic arteries and vasa brevia
run within the greater omentum adjacent to the greater curvature. These
arteries supply the stomach by sending off specific anterior and posterior
gastric branches that penetrate the stomach's muscular coat anteriorly
and posteriorly, close to the lesser and greater curvatures. On reaching
the submucosa, these gastric branches ramify extensively throughout the
entire submucosa. Maintaining a relatively large caliber, these
submucosal ramifications anastomose frequently with one another to
form the submucosal plexus, which consists of both the arteries and their
venous-counterparts. Independent branches from the submucosal plexus
supply the mucosa every where except in the lesser curvature, which
receives delicate branches from the right and left gastric arteries
(Griffith, 1955).

-.
Ulceration ofthe Lesser Curvature:
-21-
The frequent incidence of gastric ulcer along the lesser curvature
was once related to its distinctive circulation (Bentley et al., 1952). Now
with Oi's dual control mechanism as an explanation, this distinctive
circulation may be of concern only as a factor for the well-known
intractability ofmany lesser curvature ulcers (Oi et at, 1969).
Necrotic Perforation:
Of more importance IS the occurrence of necrotic perforation
along the lesser curvature after its blood supply is interrupted by parietal
vagotomy. Although several reported and unreported instances of this
frequently fatal complication occurred in the early and mid-1970s, it is
now well known that necrotic perforation is best avoided by imbricating
tile anterior and posterior gastric walls over the lesser curvature. In the
absence of these imbrications, factors other than iatrogenic injury to the
lesser curvature during parietal vagotomy (e.g. penetrating the curvature
with a clamp or burning it with use of a cautery, as proposed by many
surgeons) merit consideration. First of all, the gastric wall is thinnest
along the lesser curvature by virtue of the absence of the inner oblique
muscle. Of more importance are the vascular circumstances unique to the
lesser curvature (Griffith, 1995). In an anatomic study by angiography
in cadavers, it was shown that the left gastric arterial branches ligated
during parietal vagotomy are more or less end arteries with weak
connections to the underlying submucosal plexus (Agossou-Voyeme et
at, 1990). Unfortunately, this part of the plexus has less collateral

-22-
circulation within it than that within the rest of the submucosal plexus
throughout the entire stomach. Also, the submucosal mucosa along the
lesser curvature has relatively poor connections with the richer
submucosal mucosa immediately adjacent to it. Thus, after parietal
vagotomy, angiography shows a definite avascular band of the gastric
wall 2cm wide coursing along the operated part of the lesser curvature.
Ischemic petforations occur through this avascular band (Griffith,
1995).
CoUateral Circulation:
The large volume of blood flowing through the submucosal plexus
and the abundant anastomoses within the submucosal plexus constitute
the collateral circulation that permits extensive devascularization of the
stomach without causing necrosis (Griffith, 1995). A complete filling of
all intramural vessels of the stomach is demonstrated by injecting any of
the four major arteries after ligating all other extramural vessels. This
confirms (I) the futility of controlling haemorrhage from gastric ulcer by
ligating extrinsic arteries, (2) the viability of a stomach supplied by only
the right gastroepiploic artery (plus or minus the right gastric) and
mobilized to the chest or neck for anastomosis, (3) the viability of a
gastric remnant supplied by only the left gastroepiploic artery and vasa
brevia (after subtotal gasrectomy with ligation of the left gastric), and (4)
the viability of a small gastric cuff supplied by only descending
esophageal arteries anastomosing with the submucosal plexus after 90­
95 percent resection, in which all extrinsic vessels are ligated (Brown et
al., 1952). Fatal ischemic necrosis of the gastric remnant after gastric
resection, for example, is extremely rare, but it can and does occur. This

"
-23-
complication may be caused by atherosclerotic occlusion of the vasa
brevia and left gastroepiploic artery (Jackson, 1949), but more
commonly it is caused by insufficient blood descending from the
esophagus into the submucosal plexus (Fell et aL, 1958).
Hemorrhage:
Because of its extensive submucosal plexus, the stomach is the
most vascularized segment of the alimentary tract. The gastric mucosa
requires a tremendous amount of blood (and energy) to form and secrete
gastric juice. The smallest and most superficial erosions can hemorrhage
profusely. Surgeons must take every precaution to prevent postoperative
hemorrhage from the suture line after incising or transecting the stomach
(Griffith, 1995).
Arteriovenous Shunts:
The submucosal plexus contains many arteriovenous
shunts(Shennan et al., 1954). Vasopressin decreases bleeding from
esophageal varices by closing these arteriovenous shunts and thereby
lowering portal venous pressure(Eiseman et aI., 1960). The shunts close
to supply a maximum of blood to the mucosa for the secretion of the
gastric juice, and open to divert blood from the mucosa when the mucosa
is at rest(Peters et aI., 1958).
2. Pancreaticoduodenal Arcades:
The gastroduodenal artery usually arises from the hepatic artery or
its right and left branches and descends in a position dorsal to the most

-24-
proximal duodenum. Its first branch is the posterosuperior
pancreaticoduodenal (or retroduodenal) artery, which descends in close
association with the common bile duct (it often spirals around the distal
common duet) posterior to the head of the pancreas and posterior
duodenum. The retroduodenal artery is relatively large, and its injury by
careless duodenal mobilization, common duct exploration, or
sphincterotomy can cause brisk hemorrhage. After sending off its
retroduodenal branch, the gastroduodenal artery curves anteriorly to run
forward and medial to the duodenum, where the head of the pancreas
becomes closely attached to the duodenum The gastroduodenal artery
terminates by dividing into the right gastroepiploic and superior anterior
pancreaticoduodenal arteries (Griffith, 1995).
The posterosuperior (retroduodenal) and anterior pancreatico­
duodenal arteries anastomose with their inferior anterior and posterior
pancreaticoduodenal counterparts, which anse from the supenor
mesenteric artery (or its first jejunal branches, or its aberrant right
hepatic branch, when present). The anterior pancreaticoduodenal arcade
supplies the anterior head of the pancreas and anterior duodenum with
specific pancreatic and duodenal branches. The posterior
pancreaticoduodenal arcade supply the posterior head of the pancreas
and posterior duodenum in a similar manner. The superior and inferior
pancreaticoduodenal arteries may either branch into two to four vessels
or remain as single trunks. In any event, the anastomosis between the
superior and inferior vessels is direct and rich. This direct and rich
anastomosis in the pancreaticoduodenal arcades represents the most
important route of collateral circulation between the celiac and superior
mesenteric arteries. In only 1 percent or so of instances is it lacking, with
f

-25-
I, occurs when the gastroduodenal artery arises from the supenor
mesenteric(Griflitb, 1995). This collateral circulation cocems us in the
following respects: (1) it prevents fatal hepatic necrosis after resecting
gastric carcinoma by excising the celiac axis and the hepatic artery
proximal to the origin of the gastroduodenal artery(Clarke,I955); (2) it
is one of the several routes to the liver that explain the unpredictable
results of ligating the hepatic artery(Micbels,I953); and (3) it accounts
for the futility of ligating the gastroduodenal or superior
pancreaticoduodenal arteries to control bleeding from duodenal ulcer, for
bleeding will continue from the inferior pancreaticoduodenal arteries
(Griffith, 1995).
Another anatomic aspect of hemorrhage from the gastroduodenal
or superior pancreaticoduodenal artery cancers a selective decrease in
hepatic arterial flow. Blood destined for the liver by way of the hepatic
artery is diverted through the gastroduodenal artery and out the ulcer.
Thus, blood flow to the liver is decreased by the same mechanism as that
by which a hole in a garden hose decreases flow out of the nozzle. The
result is hepatic anoxia more severe than that caused by the total blood
loss per se (Lee Veen et at. 1952).
3. Celiac Axis:
Although the celiac artery USually trifurcates into the hepatic, left
gastric and splenic arteries, any of these three main branches may arise
independently from any of the other branches or they may branch
independently from the aorta or superior mesenteric artery. Conversely,
the superior mesenteric, middle and left colic, and dorsal pancreatic

-26-
arteries may arise from the celiac axis or from one of its main branches.
Thus, resecting the celiac axis may entail ligating more than one artery,
and, more important, it may interrupt arterial flow to the small intestine,
transverse colon, and pancreas (Appleby, 1953).
4. Left Gastric Artery:
As the left gastric artery ascends to the proximal lesser curvature,
it may send off a large left hepatic branch just before it reaches the lesser
curvature. The left hepatic artery runs within the lesser omentum to the
hilus of the liver. These aberrant left hepatic arteries carry either the
entire or partial arterial supply to the left lobe of the liver (Michels,
1955). Hence, ligating the left gastric artery proximal to the origin of its
left hepatic branch (when present) may cause left lobar hepatic necrosis
(Friesen, 1967). To emphasize the occurrence and importance of this left
hepatic artery, the French refer to the left gastric as the hepatogastric
artery. The occurrence of this aberrant left hepatic artery from the left
gastric artery depends on the variable development of an artery which, in
the embryo, runs across the lesser omentum to connect the left gastric
with the hepatic artery in the hilus of the liver. Occasionally, this
connecting artery persists, but usually it becomes oblitrated. When this
artery loses only its connection with the hepatic artery, it persists as a left
hepatic from the left gastric. When this artery loses only its connection
with the left gastric, it persists as an accessory left gastric from the
hepatic. Another source of an accessory left gastric is the splenic artery,
which from any where along its course occasionally sends a large artery
up to the posterior surface of the fundus (As a result of arteriography,
this variation has been called the posterior gastric artery). On reaching

-27-
the proximal lesser curvature, the left gastric artery bifurcates into an
ascending esophageal branch (or branches) and a descending gastric
branch, which immediately turns forward and then runs down the lesser
curvature. Usually, this descending gastric artery divides into anterior
and posterior branches, which in tum send off branches to the anterior
and posterior aspects of the lesser curvature (Griffith, 1995). The
descending left gastric artery, or its anterior descending branch,
terminates on the lesser curvature by sending out "a crew's foot type
cluster with both distal and proximal ramifications". This arterial crew's
foot accompanies the terminal branches of the anterior nerve of Latarjet,
which have also beencalled the crow's foot (payne, 1963).
5. Gastroepiploic Arteries and Vasa Brevia:
The right gastroepiploic artery usually anses from the
gastroduodenal artery, but occasionally it branches from the superior
mesenteric. It runs close to the greater curvature within the gastrocolic
ligament and supplies the stomach with independent gastric branches,
each of which divides into anterior and posterior rami that run to the
anterior and posterior aspects of the greater curvature respectively. The
left gastroepiploic artery arises from the main splenic trunk or its
terminal branches, runs adjacent to the tail of the pancreas and splenic
hilus, and reaches the greater curvature by way of the gastrosplenic
ligament. The vasa brevia usually arises from the splenic trunk or its
terminal branches, but occasionally they anse from the left
gastroepiploic artery. The vasa brevia run through the gastrosplenic
ligament to the greater curvature from the level of the spleen to the
cardia; some may reach the esophagus. Gastric branches from the vasa

-28-
brevia and left gastroepiploic artery are significantly longer than those
from the right gastroepiploic artery and, accordingly, can be more easily
ligated and transected individually in freeing the greater curvature of
omentum to remove the stomach or spleen- The pattern of anastomosis
between the right and left gastroepiploic arteries varies from no gross
connection outside the stomach to a connection so large that the exact
area of anastomosis is difficult to locate. Usually, however, the site of
anastomosis is readilyapparent (Griffith, 1995).
Pylorus and Proximal Duodenum:
The superior aspect of the pylorus and proximal duodenum is
supplied by branches of the right gastric and supraduodenal arteries
descending within the hepatoduodenal ligament The right gatsric artery
usually arises from the hepatic or left hepatic distal to the origin of the
gastroduodenal artery. The supraduodenal artery is inconstant When
present, it usually comes from the retroduodenal or gastroduodenal
artery. Because of varying arterial patterns supplying the anterosuperior
aspect of the duodenum just beyond the pylorus, the vascularity of this
specific area may be weak(Griffith, 1995). This relative ischaemia is
correlated to frequency of ulcer in this area(Reeves, 1920). However, as
in gastric ulcer of the lesser curvature, Oi's dual control mechanism has
replaced this thesis (Oi et al., 1969). Nevertheless, Mayo's "anaemic
spot" may still pertain to intractability. The gastroduodenal artery or its
pancreaticoduodenal and right gastroepiploic branches also send specific
arteries to the inferior and medial aspect of the pylorus and proximal
duodenum by way of the greater omentum. These arteries present
variable patterns. The variations, plus a scanty submucosal plexus in the

-29-
duodenum, may represent an underlying factor in necrosis and leak from
a duodenal stump or anastomsis if the duodenum has been freed
excessivelyfrom its mesenteric attachments (Griffith, 1995).

NERVE SUPPLY
A. SYMPATHETIC NERVES:
-30-
Preganglionic efferent fibers destined for the stomach and
duodenum leave the spinal cord (fifth or sixth to ninth or tenth thoracic
segment), traverse their respective sympathetic ganglia without synapse,
and unite to join the greater splanchnic nerves. On reaching the celiac
ganglia by way of the greater splanchnics, the preganglionic fibers form
a synapse with the postganglionic fibers that go to the stomach and
proximal duodenum by way of the various branches of the celiac artery.
The afferent system consists of a single neuron that returns along the
same pathways. In addition to these sympathetic fibers, the canine
abdominal vagi contain adrenergic fibers arising primarily from the
stellate ganglia (Ahlman et aI., (979). The stomach and duodenum
receive most of their sympathetic innervation from the seventh and eight
thoracic spinal segments. The pain of peptic ulcer is therefore most
commonly perceived in the seventh and eight thoracic dermatomes (the
epigastrium). Higher (fifth and sixth) or lower (ninth and tenth) thoracic
segments, however, may also contribute many fibers to the stomach and
duodenum. Thus, we encounter a few patients with peptic ulcer who
complain of pain in the lower thorax and others whose pain is around the
umbilicus(Griffith, (995).
B. PARASYMPATHETIC NERVES:
So far as is known, the vagus nerves are the sole source of
parasympathetic innervation of the foregut and midgut The existence of
a splanchnic parasympathetic system from the thoracolumbar spinal
I ....

-31-
segments in humans is only conjectural. Whereas the sympathetic system
innervates the entire embryologic gut, the vagal system innervates only
the foregut and midgut; the sacral parasympathetic system innervates the
hindgut. The boundary between the midgut and hindgut is at the splenic
flexure of the colon. At this boundary, vagal innervation ends and sacral
innervation begins; also at this boundary the superior mesenteric artery
ends and the inferior mesenteric artery begins. Preganglionic efferent
vagal fibers reach the foregut directly. Those to the midgut traverse
various autonomic ganglia without synapse and accompany the arterial
supply to the liver, biliary tract, and intestine. The preganglionic fibers
synapse with the postganglionic fibers in the intramural plexuses of the
gut (Griffith, 1995).
1. Vagi from Thorax to Abdomen:
Below each pulmonary hilus, the left and right vagus nerves
descend on either side of the esophagus and, in the lower thorax, branch
and communicate with each other as the esophageal plexus around the
esophagus. Depending on the variable number of branches that each
vagus nerve contributes to form this plexus, the complexity of the plexus
varies from body to body. The branches of the esophageal plexus then
unite to form two, and only two, vagal trunks-one anterior and the other
posterior to the esophagus. The anterior vagal trunk divides into the
anterior gastric and hepatic vagal divisions. The posterior trunk divides
into the posterior gastric and celiac vagal divisions (Griffith, 1995).

2. Abdominal Vagi:
a. The Anterior Vagus:
-32-
The anterior vagi are conceived in terms of three components: (1)
the hepatic division, (2)the pyloric nerve of McCrea (McCrea, 1924),
and (3) the anterior gastric division. The last was termed the principal or
greater anterior gastric nerve by Latarjet (1921) and his student
Wertheimer (1922); it is now commonly called the nerve of Latarjet,
The pyloric nerve of McCrea is more often absent than present. When
absent, its pyloric fibers are most commonly a part of the hepatic
division and descend to the pylorus (and distal antrum and proximal
duodenum) within the hepatoduodenal ligament, usually in company
with the right gastric artery. In its classic position, the pyloric nerve runs
within the lesser omentum midway between the hepatic and anterior
gastric divisions to the distal antrum and pylorus. In a lower position, the
nerve of McCrea runs just above and parallel to the nerve of Latarjet. In
this pattern, Loeweneck et al, (1967) called McCrea's pyloric nerve the
antral nerve, and others have referred to the double nerve of Loeweneck.
Finally, the nerves of McCrea and Latarjet may be incorporated into one
nerve, which runs all the way to the pulorus and, rarely, onto the
proximal duodenum (Fig. 3) The hepatic division is constant from the
standpoint that it can always be seen within the stretched-out lesser
omentum just beneath the under surface of the liver in contrast against
the dark background of the caudate lobe of the liver. Usually as a few
small fibers in parallel, the hepatic vagi accompany the vestige of the left
hepatic artery from the left gastric artery (or with this aberrant left
hepatic artery when it is present) within the lesser omentum to the

. The Posterior Vagus:
-34-
The posterior vagus runs down behind and separate from the
esophagus and upper gastric wall to the level of the left gastric artery
where it becomes closely applied to the lesser curvature (Taylor, 1979).
The posterior vagi consist of the posterior gastric division (posterior
nerve of Latarjet) and the celiac division. No specific posterior pyloric
nerve exists. Although the posterior nerve of Latarjet reaches the distal
antrum in a few bodies, it is usually shorter and has fewer gastric
branches than the anterior nerve. Aside from these differences, the
posterior gastric nerve may be conceived as the counterpart of the'
anterior nerve (Griffith, 1995). The celiac division is constant in two
respects. First, it is the largest of the tour truncal divisions and may be
conceived of as the continuation of the posterior trunk. Second, it always
descends within the pancreaticoduodenal fold as one large fiber to the
celiac and superior mesenteric autonomic plexuses. Two variations are
of surgical irnponanee. The first concerns its variable positions within
the pancreaticoduodenal fold. Second, as the posterior trunk-celiac
division, some or all of the posterior gastric vagi may arise just above the
celiac plexus and accompany the left gastric artery to the stomach
(Jackson, 1949) (Fig. 4).

-36-
enough to cause recurrence after conventional parietal vagotomy. When
the gastroepiploic nerves are divided by ligating and transecting the
gastroepiploic pedicles it is termed extended highly selective vagotomy
(Donahue et al., 1993).
To the best of my knowledge, the anatomic routes of the
gastroepiploic nerves have not yet been demonstrated by gross
dissections. From their many experimental studies, Donahue et
al.,(1993) infer that these nerves arise from the most distal branches of
the nerves of Latarjet and pursue intramuscular courses through the
pylorus and duodenum, but where and how they emerge into the greater
omentum is unknown (Griffith, 1995). Others have proposed that the
gastroepiploic nerves arise from some of the descending hepatic vagal
fibers and reach the greater curvature in company with major arteries
(the gastroduodenal and its gastroepiploic branch on the right and the
common hepatic, splenic and its gastroepiploic branch on the
left)(Berthoud et al., 1991). However, this proposal is at odds with all
our experimental and clinical studies of selective gastric vagotomy,
which show that neither the hepatic nor the celiac vagi send efferent
motile or secretory fibers to the stomach (Griffith, 1995).
Segmental Innervation ofThe Stomach:
The fibers from each left and right vagus nerve are distributed
diffusely throughout the parietal mucosa as a result of their intermingling
with one another in the esophageal plexus. At the level of this plexus,
however, innervation becomes segmental- Each branch of the esophageal
plexus innervates a segment of parietal mucosa via the vagal trunk to
which it contributes. The anterior and posterior gastric divisions from the

anterior and posterior trunks innervate the anterior and posterior mucosal
surfaces, respectively, and each terminal branch from the gastric
divisions (nerves of Latarjet) innervates its own small segment of
parietal mucosa. Furthermore, by correlating the amount of innervated
mucosa with the amount of the contractile response of the stomach, we
showed that each end branch innervates its own small segment of
muscle. Thus, the demonstration of segmental innervation of both the
parietal mucosa and gastric muscle indicates that the innervation of the
whole stomach is segmental (Jones et aI., 1970). The method using
neutral red did not permit visualization of the exact pattern of
innervation of the antral mucosa. However, this method did permit
demonstration of two distinct anatomic routes for innervation of the
antnun. The extramural route is from the end branches of the nerves of
Latarjet. The intramural route is from more proximal branches of the
nerves of Latarjet that run in the submucosa beneath the parietal mucosa
to the antral mucosa (Legros et al., 1969).
Anatomic Basis for Parietal Vagotomy:
Both Dragstedt(1968) and Hollander(l956) rejected our initial
experiments because, at that time, they and all other physiologists and
surgeons believed that vagotomy obeyed the law of all or non. This law,
as expressed by Dragstedt et al.,(1947), held that any single fiber
remaining after an incomplete vagotomy "appears to be able to activate
the entire glandular apparatus, acting presumably through the
submucosal plexus of Meissner". It therefore followed that the intact
vagal fibers to the antrum after parietal vagotomy would activate the
corpus and fundus. They also objected to selective vagotomy and

-38-
postulated that intact hepatic and celiac vagal fibers might reach the
stomach by circuitous pathways through their respective autonomic
plexuses (Griffith, 1995). Using methods of both motility and secretion,
we showed that the hepatic and celiac vagi do not innervate the stomach
and therefore, that selective vagotomy provides a complete gastric
vagotomy (Stavney, 1963).
Finally, after some 10 years of fiuitless effort, we proved that
vagal innervation of the stomach is segmental. Although this finding
revealed that the parietal mucosa could be selectively vagotomized, the
question arose whether the residually innervated antral mucosa could
reinnervate the denervated parietal mucosa by sprouting. Long-term
experiments showed that this type of reinnervation is probably
insignificant (Griffith, 1995).
The Proximal Extent ofParietal Vagotomy:
Dissection of the distal esophagus for parietal selective and total
vagotomy concerns the proximal extent of parietal vagotomy, which
even though complete, does not prevent recurrence (Amdrup, 1982).
The fibers in question may lie within or deep to the esophageal fascia
propria but not deep the esophageal muscle. The latter fibers innervate
the esophagus and not the stomach(Skandalakis, 1981). To accomplish
a complete vagotomy, therefore, the esophagus need not be circumcised
or perforated (Griffith, 1995).
....

-39-
The Distal Extent of Parietal Vagotomy:
The distal extent of parietal vagotomy concerns two anatomic
variations- the variable extent of the parietal mucosa distally and the
variable lengths of the anterior nerve of Latarjet (Griffith, 1995). If the
vagotomy is extended to a point on the lesser curvature 6cm from the
pylorus (which is about as far as can go and still preserve enough antral
motility to prevent gastric stasis), denervation of the distal parietal
mucosa will be complete in most patients. In other patients, the
vagotomy of the distal parietal mucosa is incomplete, but the area of
incompleteness is not large enough to cause recurrence, and the
vagotomy is therefore adequate. In smaller numbers of patients, perhaps
5 percent or fewer, the parietal mucosa extends to distances, 4,3 and
even less than 2cm from the pylorus. In these patients with a
correspondingly and extremely small areas of antral mucosa, the area of
the residually innervated distal parietal mucosa may be large enough for
the incomplete vagotomy to be inadequate (Richter et aI., 1987).
With regard to the variable length of the anterior nerve of Latarjet,
at one extreme is the nerve that contains all the pyloric fibers from the
hepatic division and the nerve of McCrea and runs all the way to and
beyond the pylorus. At the other extreme is the considerably shorter
nerve that contains no pyloric fibers, which in these instances, are carried
in either or both the hepatic division and nerve of McCrea. These short
nerves of Latarjet barely reach 6-cm point from the pylorus and, in a few
bodies, end well proximal to this point (Skandalakis et aI., 1980). The
shortest nerve of Latarjet ended a measured 8.5cm from the pyloric ring
(Nielsen et al., 1981). Thus, there is no correlation between the distal
extent of the anterior nerve ofLatarjet and the distal extent ofthe parietal

-40-
mucosa (Poppen et al., 1976)_ The patients of concern are those who
have extremely small antra and extremely short nerves of Latarjet and
who, therefore, have sizable areas of residual innervation in the distal
parietal mucosa after parietal vagotomy. The terminal branches of the
anterior nerve of Latarjet on the lesser curvature have been termed the
crow's foot and have been used as a landmark for the distal extent of the
parietal vagotomy. Although not all that constant, the crow's foot
landmark has proved workable in most patients (Griffith, 1995).
/ .o(

PHYSIOLOGY
GASTRIC PHYSIOLOGY:
-41-
The four basic functions of the stomach are to store, sterilize, mix
and deliver ingested food in suitable form to the small intestine. The
mechanisms by which the stomach achieves these functions depend on
an integration of humoral, nervous electrophysiologic, and
physicochemical activities. Although performing its function as an
integrated organ, the stomach actually is two organs in series-namely,
the gastric body and fundus and the gastric antrum, the former producing
predominantly acidic secretions in the form of hydrochloric acid,
enzymes, intrinsic factor and electrolytes, and being associated with
storage capacity, and the latter producing bicarbonate secretions and
antral gastrin and being associated with the powerfull muscular activity
that mixes and sieves the gastric chyme in preparation for its coordinated
delivery to the duodenum and small intestine ( . 5) (Elder et at, 1995).
A-Storage Function:
The capacity to eat a meal, sometimes of several courses over a
relatively short time, demands that the stomach achieve isometric
adaptive relaxation to develop the storage capacity without discomfort.
This function depends on intact vagal pathways, whose cell bodies
originate in the dorsal motor nucleus of the vagus in the floor of the
fourth ventricle in the brain stem. Most vagal fibers (90 percent) arc
afferent in carrying massages back from the stomach to the brain stem
(Allen et al.,l980). In the stomach itself, these fibers originate from
stretch receptors in the muscle wall as well as from nerve filaments

-42-
adjacent to epithelial cells, and the rate of discharge increases on passive
distention of the stomach during eating. This sets up long vagal reflex
arcs via the brain stem, which are integral to the process of adaptive
relaxation.
Fig (5): Schematic representation of vagal pathways, gastrin effects, and
local reflex arcs in stomach active in the control of gastric acid secretion.
EeL :::: enterochromaffin-like ceUs (Elder et at, 1995).

-43-
There are other slower-acting chemoreceptors originating from
small nerves m the mucosa that probably ere involved in local
submucosal and myenteric plexus reflexes. Many of the cells in these
plexuses contain neuropeptides (Buck et al., 1986). Predominant among
these is vasoactive intestinal peptide. It has a role in stimulating smooth
muscle contraction in the arterioles adapting blood flow and is involved
in the control of mucus and electrolyte secretion. The vagus nerve is
involved also in inhibition of antral motility as part of a neurohumoral
mechanism when fat, acid, peptides, or amino acids such as tryptophan
enter into the duodenum and smallintestine (Mercer et al., 1990).
The storage function of the stomach therefore is largely dependent
on intact vagal nerve pathways and although some adaptation occurs
after proximal gastric vagotomy in humans, impairment of this function
has been noted. Predictably, vagotomy changes the pattern of muscle
contraction and leaves the stomach atonic and dilated, retaining its
content for a variable period of time, the procedure results in an
incoordination of gastric emptying, necessitating a drainage procedure­
either pyloroplasty or gastroenterostomy after a truncal vagotomy. This
is avoided after a highly S(;: ••.ctive vagotomy where vagal antral
innervationis preserved (Madara, I 991).
B. Acid Secretion: A Sterilizing Force:
The stomach is a unique organ in that the glands in the body can
achieve extremely high concentrations of protons (hydrogen ions) within
the parietal cells as well as in the lumen of the stomach, achieving a
concentration gradient with respect to H+ ions of 2.5 million-fold. It
... would seem that the main function of secreting such a powerful acid as

Hcl is to achieve a low pH that will sterilize the food. The stomach
secretes approximately 2500 ml of gastric juice per day. The gastric
glands of the fundus and body of the stomach contain both parietal and
chief or peptic cells and, under appropriate stimulation, these glands can
secrete a fluid containing Bel at a concentration approaching 150 mmol
(Elder et at, 1995).
Acid secretion results after cholenergic stimulation by
acetylcholine, by gastrin and, perhaps most importantly, after histamine.
Recently, it has been proposed that histamine is almost certainly the final
common pathway for stimulation of parietal cells and is released from
enterochromaffin-like cells. Histamine then is bound specifically to the
H2 receptors at the basolateral membrane of the parietal cell and incites
acid stimulation directly via an increase in and activity of basolateral
adenylate cyclase adenosine 3':5'-cyclic phosphatase (Macdennott et
al; 1991) (FiR 6).
Acid secretion is incited initially by psychic stimuli mediated by the
vagus nerves and triggered by the sight, smell, anticipation, and taste of
food (Elder et al., 1995).
...

-,
..........v··
-45-
ECL-CELL
PARIETAL CELL
Fig. 6. Probable role of histamine in the final common pathway of
stimulation of acid secretion. EeL = enterochromaffin-like (Elder et al.,
1995).
Postganglionic vagal nerve fibers innervate the antral G cells,
releasing gastrin-releasing peptide as a transmitter; m addition, the
products of protein digestion, chiefly amino acids m the stomach,
stimulate G cells directly. Gastrin circulates through the portal and
systemic routes to receptors on parietal ceUs and enterochromaffin-like
cells (Le et til., 1987). As gastric pH decreases as a consequence of
increased acid secretion, inhibition of gastrin release takes place when
the lumenal pH reaches 3. There is, therefore, a "gastrin response" to
each meal, which has been shown to be exaggerated in patients with
duodenal ulcer disease(Ritchie et at, 1991) (Fig. 7).

-48-
The gastric fundus itself does not participate in active peristalsis (Elder
et at, 1995).
D. The Delivery System for Gastric Chyme:
In general, the proximal stomach functions largely as reservoir,
whereas the more muscular and distal antrum acts as a grinder, a sieve
and is the propulsive part of the stomach for delivering chyme into the
duodenum (Elder et 81, 1995).
Gastric emptying is a complex result of several integrated
responses, determined by the volume of the meal, the liquid and solid
components, and individual characteristics of each of those components.
Increasing concentrations of nutrients, salts and acids in a liquid meal
results in fairly slow gastric emptying and conversely, nutrients or acids
at low concentrations are emptied more quickly than those at high
concentrations, the result being that the amount of nutrient or acid
entering the duodenum over time remains constant (Davenport, 1972).
The initial concentration of liquid nutrient entering the duodenum at the
beginning of gastric emptying plays a v""ry important part in determining
the pattern of emptying that follows. In general, there is a rapid initial
and then a slower subsequent phase for the emptying of liquids. All
forms of gastric denervation-that is, truncal vagotomy, selective gastric
vagotomy, and proximal gastric vagotomy-accelerate the initial
emptying phase for liquids, as does antral resection. Emptying of solids
from the stomach follows a course different from that of liquids, and
studies using radio-labeled foods or plastic markers have revealed a time
course of gastric emptying that is more a segmoid pattern than linear,
often accompanied by a long initial lag phase during which non of the
•.

-..,.
-49-
, marker or the radio-labeled meat appears to empty. The two-component
hypothesis describing liquid and solid emptying separately does not
totally account for the observed patterns of gastric emptying in humans;
it is likely that several mechanisms, such as proximal gastric tone, antral
contractility, pyloric resistance, duodenal resistance, and gastroduodenal
coordination, are all integrated in response to varying stimuli to produce
the patterns seen in the intact human (Elder et at, 1995).
The electrical stimulation of the anterior nerve of Latarjet
produced contractile activity on both anterior and posterior surfaces of
the antrum, indicating that axons of neurons from the front of the
stomach cross over to the back, thereby essentially maintaining the
potential for normal gastric emptying. This was true crossover
innervation and was not due to the propagation of conduction of
electrical response activity. They found that contractions induced locally
by injection of acetylcholine into a small artery did not propagate. The
cross-over innervation and the direct innervation were both segmental.
This work suggests that the maintenance of the antral branches of the
anterior nerve of Latarjet is all that is required for the full functional
mobility ofthe antral musculature (Taylor et at, 1982).
Johnston, (1970) decided that denervation to within 6 cm of the
pylorus on the lesser curve was likely to denervate nearly aU the parietal
cells, Later studies with an intra-gastric pH probe confirmed this level,
which usually meant that only one distal branch of the nerve of Latarjet
remained (Johnson, 2000).

Physiologic Basis ofVagotomy:
-50-
Although vagotomy undoubtedly blocks the cephalic phase of
gastric secretion, it also reduces the sensitivity of the parietal cells to
circulating gastrin, reducing the acid response to pentagastrin or
histamine by 65-70 percent (Christiansen et aI., 1981). Vagotomy, like
atropine, completely abolishes the acid response to modified sham
feeding in humans, while having no effect on gastrin release in either
normal or DU patients (Konturek et al., 1979). In addition to acid
secretion, the vagus nerve influences receptive relaxation of the stomach
and antral motility as well as function of the liver, pancreas, and small
intestine. It is surprising that TV has so few side effects and how well the
other control mechanisms can compensate (Johnson, 1995).
-Regeneration ofNerves?
That there was an Increase in the recurrence of duodenal ulcer
with time and an increase in the positive rate with insulin test suggested
that divided nerves might regenerate (Johnson, 2000). Regeneration
would require sprouting to occur across a 1-2cm gap and for the minority
of efferent nerves to grow along the appropriate axon sheaths. Such
efficient nerve regeneration would seem unlikely and indeed acid
secretory studies perfurmed up to I year after myotomy do not show
evidence of a major degree of regeneration. Amdrup et al., (1969)
stated that in their experience the amount of mucosal reinnervation
occurring as a result of the phenomenon of sprouting is insignificant
(Taylor, 1979). The concept of nerves crossing large gaps by sprouting
is not supported by the facts, but it is possible that a small nerve left in
one part of the parietal cell mass could spread the innervation to other ....

-51-
parts with time. Experimental studies show that it appears to take place
in a proximal to distal manner rather than the other way around, so
adequate denervation in the upper part of the stomach is particularly
important (Johnson, 2000).
-Adequacy ofincomplete vagotomy:
Of principal concern is the process of sprouting, which can occur
only if vagotomy is incomplete. Intact postganglionic fibrils at the
cellular level in the residually innervated mucosa send out sprouts that
reinnervate cells in the adjacent denervated mucosa (Murray, 1959).
Another concern is vagal reinnervation by restoration of continuity of
divided nerve ends. Specifically, no one has correlated any restoration of
continuity of divided vagal fibers with a resultant return of increased
gastric secretion in either animals or humans (Griffith, 1995).
All types of vagotomy transect preganglionic fibers which are
incapable of restoring end-to-end continuity with any return of function.
Preganglionic fibers also can not sprout. Thus, the proposal, particularly
after parietal vagotomy, that the proximal ends of the transected fibers
may send out fibrils (or sprouts) that penetrate the gastric wall to
reinnervate muscle and mucosa is based on unfounded speculation
(Dragstedt et al., 1950). Sprouts grow only from postganglionic fibers
innervated by intact preganglionic fibers. Sprouting is a microscopic
process within muscle submucosa at the periphery of areas of residual
innervation and is limited in both time and extent to minimal
reinnervation of the adjacent denervated tissue (Murray, 1959). Up to
this point, I have stated that sprouting is probably insignificant and that

-52-
an incomplete but adequate vagotomy remains permanently adequate
(Griffith, 1995).
When HoUander,(1956) devised his criteria for interpreting his
insulin test, he believed vagotomy obeyed the law of all or none and
assumed there were "no degrees of vagality". He therefore interpreted
his results only as negative or positive. TIlls interpretation still is used in
many centers, despite the fact that it denies the occurrence of various
types of incomplete vagotomy with variable degrees of adequacy. We
compared the insulin responses of an intact trunk with an intact fundic
branch. There are indeed variable degrees of vagality Legros et al.,
(1968). Consequently, as proposed by Ross et al., (1964), positive
insulin responses are classified as adequate or inadequate. The former
response is typically small and delayed and indicates adequate protection
against recurrent ulcer; the latter is large and early and indicates
inadequate protection against recurrence. These two examples of
incomplete vagotomy represent the extremes of adequacy and do not
include the shades of gray between. Nonetheless, these revised criteria
have proved to work well in differentiating the incomplete vagotomy
that causes recurrence from that which does not and they arc much more
useful than Hollander's original criteria (Bell, 1966).

-54-
Peptic ulceration is a common disease in civilized countries and it has
been estimated that about 10010 of aU people suffer from peptic ulceration
during some stage oftheir life (Rifaat, 1988).
Age Incidence:
Duodenal ulcers are rare in people younger than 15 years, and their
incidence reaches a peak between ages 35 and 44 in both men and
women (Langman, 1974).
Sex Ratio:
In 1938, the male-female ratio was 4.5: I, and the ratio has
progressively decreased year by year until currently it is approximately
2: I (Monson et al., 1969).
LOCATION:
Most duodenal ulcers occur in the first part of the duodenum, but
ulcers occurring in different locations must be considered also, in
particular those occurring just proximal to the pyloric sphincter, those in
the pyloric canal, and those distal to the pulb and in the descending and
other portions ofthe duodenum (Kaufman et at, 1957).
The ulcers. whether esophageal, gastric, or duodenal occur at
mucsal junctions. The pyloroduodenai mucosal boundary was sharp and
distinct and might extend for approximately 2 em on either side of the
apex of the pyloric muscular ring (Oi et al., 1959). This provides an
anatomic explanation for the prepyloric ulcer that has all the

-55-
characteristics of a duodenal ulcer: the ulcer IS located III duodenal
mucosa (Christopher et al., J995).
AETIOLOGY:
Most duodenal ulcers are due to gastric hypersecretion of acid and
pepsin and only a few are due to extragastric factors (Rifaat, 1988)
(A) Gastric Hyperacidity:
Clinical and experimental observations indicate that a relative or
absolute excess of acid - pepsin in the gastric secretion is the essential
factor in the pathogenesis ofchronic duodenal ulcer (Rifaat, 1988).
1. Large parietal-cell mass:
The total number of parietal cells counted postmortem in the
stomachs of duodenum ulcer patients is about twice that found in the
stomachs without ulcers, and it has been found that doudcnal ulcers do
not occur below a threshold parietal-cell count of 10 9 (Rifaat, 1988). The
stomachs of those who had duodenal ulcers were larger, thicker, and
more densely populated with parietal cells than normal (Cox, 1952). The
greater parietal cell mass may be a genetically inherited trait or may be
the result of work hyperplasia in response to prolonged stimulation. It
has been suggested that the predominance of duodenal ulcer in males
may be due to the met that generally men have more parietal cells than
females (Rifnt, 1988).

2_ Vagal over-activity:
-56-
The vagus nerve is to a great extent responsible for the secretion,
tone and motility of the stomach and it has been suggested that increased
vagal impulses of subconscious origin may be responsible for the
hypersecretion accompanying duodenal ulcer- In duodenal ulcer patients,
the vagal tone is usually abnormally high and the patient is nervous and
irritable and often a heavy smoker (Rifaat, 1988).
3. Hormonal over stimulation:
Except in the Zollinger-Ellison syndrome, serum gastrin essays
have shown that the fasting serum gastrin levels are not higher in ulcer
patients than in control subjects. However, it is possible that dietetic
indiscretions, such as alcoholic excess and ingestion of spiced foods,
may cause excessive hormonal stimulation of gastric secretion (Ritaat,
1988). It has been abundantly recorded that persons with chronic
duodenal ulcers secrete, on average, more acid at night, while fasting,
and in response to food and stimulants than do those without such ulcers
(Fordtran et al., 1973).
4. Helioobacter pylori infection:
Helicobacter pylori enhance the risk for ulcer disease and gastric
cancer (Atherton, 2001)_ It has been established beyond reasonable
doubt that infection with the spiral, motile organism Helicobacter pylori
bears a causal relationship with gastric and duodenal ulcer. H pylori in
metaplastic gastric mucosa in the duodenum causes duodenal ulcer.
The familiality of duodenal ulcer may be cross-infection with II
pylori in the family (Chrisopher et at, 1995).

-57-
5. Usc ofnon-steroidal anti-inflammatory drugs:
Most cases of peptic ulceration in the absence of Helicobacter
pylori are associated with the use of NSALDs, particularly in the elderly.
Many of these patients can not stop taking these drugs because they
become incapacitated by their arthritis (Johnson, 2(00).
(B)Extragastric Factors: (Rifaat, 1988)
Certain genetic factors and disease states predispose to duodenal
ulcer in a way not always related to gastric secretion.
I. Genetic Factors:
An excess of ulcer disease exists among siblings of ulcer patients
and it has been found that subjects with blood group 0 are more
prevalent among ulcer patients than in the control population. Another
important genetic factor is the "secretory status of the individual.
Approximately, 75% of human individuals arc "secretors", i.e. they
secrete into their saliva, gastric juice and urine, water-soluble blood
group antigens identical to those on their red blood cells. 'The remainders
are "non-secretors" and instead of their major blood group antigen, they
secrete the Lewis antigen. These "non- secretors" arc more liable to
duodenal ulceration than secretors,

2, Hyperparathyroidism:
-58-
Primary hyperparathyroidism is associated with a higher incidence
of duodenal ulcer In some cases, the ulceration is due to an associated
gastrin-secreting panreatic tumour (Zollinger-Ellison syndrome) while in
others it seems to be due to the hypercalcaemia which results in gastric
hypersecretion,
3. Chronic pancreatitis:
Although patients with chronic pancreatitis do not secrete more acid
than healthy subjects, they show an increased susceptibility to peptic
ulceration, particularly duodenal. Because chronic pancreatitis IS
associated with low bicarbonate content of the pancreatic juice, the
ulceration is probably due to decreased buffering capacity of the
duodenal secretions.
4. Liver disease:
Cirrhotics are particularly liable to acute erosrve gastritis and
chronic peptic ulceration However, their gastric acidity is lower than in
healthy individuals and much lower than the acidity usually
accompanying duodenal ulcer,
< Pulmonary disease:
Peptic ulcer is at least 3 times more common m patients with
pulmonary emphysema than in the general population. Conversely,
emphysema occurs 3 to 4 times more often in patients with peptic ulcer

-59-
than would be expected from the usual incidence of emphysema in the
general population. Probably, the hypercapnoea of chronic lung disease
predispose to the peptic ulceration.
PATHOLOGY and PATHOGENESIS:
-Mucosal Protective Factors:
Ulceration is inevitably the failure of the mucosa either to protect
itself or to regenerate at a rate sufficient to replace lost cells. Various
cytoprotective mechanisms exist that affect the duodenal epithelium.
These include the mucous layer, which prevents acid and pepsin from
coming into contact with the luminal aspect of the cell. Bicarbonate is
secreted by the duodenal mucosa, is present in pancreatic juice, and has
the effect of neutralizing hydrogen ions deep to the mucosal layer
(Christopher et aI., 1995). Other factors include prostaglandin £2,
which, in addition to inhibiting acid secretion, has another much less
well-defined effect that can be demonstrated: Surface active
phospholipids have been shown to protect the _gastric, and possibly
duodenal as well as epithelial, cell in the experimental animal, but
interference with this mechanism by ethanol and H. pylori may
predispose to their damage (Hills, 1993). Mucosal blood flow is another
important factor (Jacobson, 1992). Nitric oxide produce divergent
effects, and its donators are concerned with the regulation of mucosal
blood flow and, therefore, its protection (Lopez et at, 1993).

-60-
- Characteristics of chronic duodenal'ulcer:
Chronic duodenal ulcer is usually solitary and always situated in the
supra-ampullary portion of the duodenum. Sometimes, two ulcers are
present, one on the anterior surface and the other on the posterior surface
of the first inch of the duodenum (kissing ulcers), and, occasionally, a
duodenal ulcer is associated with a chronic gastric ulcer in the pyloric
region of the stomach (combined ulcers). The ulcer is usually round or
oval and small, measuring I inch or less in diameter. The edges are
regular and sharply defined, extending steeply to the floor to produce a
pouched-out appearance. The floor is deep and regular with an indurated
fibrous base. Almost invariably, there is complete destruction of the
muscle coat so that the floor is formed by the thickened subserous layer
alone. The surrounding mucosa is often thrown into folds which
converge on the ulcer as a result of scarring. The serosa is thickened and
scarred when rubbed gently with a swab, it becomes stippled with
numerous capillary vessels and petechial haemorrhages (stippling sign).
The related omentum is often thickened and scarred and there may be
multiple adhesions to neighbouring organs (Rifaat, 1988). Gastric outlet
stenosis incites dilatation of the stomach with hypertrophy of the gastric
musculature and increased acid output, thus increasing the
aggressivenessofthe process ofulceration (Taylor, 1995).
- Mucosal Regeneration:
The epithelial cells surrounding a duodenal ulcer replicate at a
greater rate than normal. Those closest to the ulcer edge divide more
rapidly than those further away (Smedley et at, 1988). The mechanism
.I

-61-
responsible for this almost certainly involves epidermal growth factors
(EGFs) suggested by the demonstration of an increase of EGF receptor
expression on cells at the edge of a peptic ulcer (Tarnawski et al.,
1992). Epidermal growth factor has been shown to influence the rate of
cell proliferation in the small intestine (Coodlad, 1989), and salivary
EGF may promote healing of peptic ulcer (Konturek, 1990).
Transforming growth factor alpha interacts with the same receptor as
EGF and is also found in gastric mucosal cells (Polk et al., 1992). Basic
fibroblast growth factor is responsible for angiogenesis and may be
important in ulcer healing (Folkman et aI., 1991). Insulin-like growth
factors are also found in the proliferating margin of crypt cells in the
small intestine (Vanderhoffet al., 1992).
- Helicobacter pylori:
The organism is characterized by a powerful urease with resultant
production of amonia from urea. It exists deep to the mucous layer of the
stomach, its distribution being dependent on the acid-secreting
characteristics. In high secretory states, the orgarusrn tends to be
distributed more distally and, if acid secretion is low or inhibiu.,', the
proximal area of infection migrates cephalad. Apart from the pH effects
of infection, the organism has been shown to interfere with the surfactant
effect of surface-active phospholipids, which protect the epithelial cell.
There is also electron-microscopical evidence to suggest that H. pylori
ingests these phospholipid, even perhaps employing them for self­
protection (Hills, 1993). More difficult to establish is the precise
relationship with duodenal ulcer production. One suggestion is the
gastrin mechanism: The release of ammonia ions in close association

-62-
with the antrum tends to maintain a high pH favoring continual secretion
of gastrin and, thereby, acid. Hypergastrinemia has been demonstrated in
infected patients compared with controls. Eradication of H pylori has
been shown to result in a reduction in gastrin level to normal (Prewett et
at,I991).
CLINICAL PICTURE:
The cardinal symptom of duodenal ulcer is epigastric pain, located
midway between the xiphisternum and umbilicus and slightly to the right of
the midline. When the patient is asked to indicate the site of his pain, he can
often localize the pain accurately with a fmger or group of fingers. A positive
pointing test is the most valuable sign of chronic duodenal ulcer. Deep
palpation usually reveals tenderness in the mid-epigastrium, either in the
middle line or just to the right of it, but never to the left. During acute
exacerbations, slight rigidity may be elicited over the upper part of the right
rectus muscle (Rifaat, t 988). The pain commonly wakes the patient at night,
often at approximately 2:00 AM (Christopher et al., 1995). The ulcer pain is
relieved by anything that dilutes or buffers the gastric acid, e.g, plain water,
milk, antacids or food. As a I esult, the patient often carries biscuits and
alkaline tablets in his pockets and keeps a glass of milk by his bedside at night
(Rifaat, 1988).
Heartburn occurs in a number of patients, but it usually follows closely
the development of the abdominal pain (Christopher et al., 1995). Acid
eructations are common complaints but vomiting seldom occur spontaneously
and when it does it relieves the patient so that it is frequently self-induced.

-63-
Since the appetite is good and food apparently relieves the pain, no loss of
weight occurs and the patient may even gain weight (Rifaat, 1988).
When symptoms first occur, they usually arc troublesome for several
hours each day for a period of I to 2 weeks. This experience is followed by a
remission period, often extending for several months. The cycle then is
repeated, with the difference that the episodes of pain become longer and the
periods ofremission shorter (Christopher et al., 19(5).
DIAGNOSIS & INVESTIGAnONS:
The mainstays of objective diagnosis are the barium meal
examination and endoscopy. Together these two procedures provide
considerable accuracy (Barnes et al., 1974). The diagnosis can be made
with absolute certainty only by endoscopy or direct inspection
(Christopher et aI., 1995).
COMPLICATIONS:
In many countries, there is steady increase In the incidence of
complications of peptic ulcer in patients of both sexes older than 65
years (Johnson, 1995). Over four thousand people die annually in
England and Wales from peptic ulcer disease(Taylor et aI., Dec. 1985).
A possible explanation for the marked increase in ulcer-associated
mortality in the elderly woman is the increased use of non-steroidal anti­
inflammatory drugs (NSAIDs) that has occurred in recent years. Other
possibility that may be considered to account for this rise in mortality are
the increased incidence of colonization of the stomach and duodenum by

-64-
II. pylori and the marked reduction In use of peptic ulcer elective
surgical procedures (Taylor, 1995).
On reaching the age of 50 years, duodenal ulcer patients (both male
and female) run a 25 percent risk of significant ulcer haemorrhage within
the next decade of their lives. The corresponding risk figures for
perforation over the decade between the ages of 50 and 60 years are 9
percent for men and 7 percent for women. With each subsequent decade
thereafter, these incidences rise. The overall mortality for upper
gastrointestinal bleeding remains today, as it has throughout this century,
at 10 percent, and the mortality for ulcer perforation is at least 10 percent
(Pulvertaft, 1968). Apart from perforation and hemorrhage, chronic
duodenal ulcer may result in stenosis of the first part of the duodenum
(Christopher et aL, 1995). Gastric outlet stenosis is produced by
aggressive duodenal ulceration, which lays down dense fibrous tissue in
the region of the ulcer. Gastric outlet stenosis incites dilatation of the
stomach with hypertrophy of the gastric musculature and increased acid
output, thus increasing the aggressiveness of the process of ulceration.
The aggressive posterior duodenal ulcer, which may penetrate into the
pancreas or posterior abdominal wall, sometimes giVing nse to
pancreatitis or abscess formation (Taylor, 1995).

-65-
TREATMENT OF CHRONIC DUODENAL ULCER:
The massive changes in the treatment of duodenal ulcer disease that
have taken place in recent years as a result of the availability of
efficacious medical treatment have called into question the role of
elective surgical intervention in the treatment of this condition (Taylor,
1995). It is beyond dispute that a major decline has occurred in the
number of patients undergoing elective duodenal ulcer surgery (Taylor
et aI., 1990).
Currently there are three options for medical therapy of ulcer
disease: H2-receptor antagonists (H2-RAs), proton pump inhibitors, and
triple therapy. Acid suppression either by blocking the H2-receptors or
proton pump inhibitors has the intrinsic disadvantage of recurrence
without expensive, long-term maintenance therapy Triple therapy is
designed to eradicate the underlying H pylori infection (Cuschieri,
1995). The vast majority of ulcers can be healed by these acid-reducing
drugs, but long-term continuous maintenance therapy is essential to
avoid recurrence allll complications. The reduction in the incidence of
serious complications (hemorrhage and perforation) by H2RA therapy
appears to be of the same order at; that achieved by ulcer surgery. Some
10-15 percent of patients prove refractory (non-healing after 2 months of
therapy) to H2RAs (penston et aL, 1992),
Omeprazol and lansoprazol produce covalent (reversible) inhibition
of the acid proton pump. Acid secretion is suppressed, and the pH of the
gastric contents remains above 3.0 for at least 16 hours per 24-hour
period while the patient is on treatment. However, maintenance therapy
is necessary to prevent recurrence and reduce complications (Bader et
at, 1989). Long-term therapy with proton pump inhibitors has its

-66-
problems. These are the consequence of the profound acid inhibition and
include persistent hypergastrinemia with hyperplasia of the
enterochromaffin cells, bacterial overgrowth of the upper gastrointestinal
tract, and the risk of infections. Others are metabolic in nature:
malabsorption of vitamin B12 with reduction of the body stores of this
vitamin and reduction of the serum iron levels with development of iron­
deficiency anemia (Koop, 1992). Awareness of the limitations of triple
therapy is, therefore, important since this therapeutic approach has
several problems. There is a high noncompliance rate due to the side
effects of therapy and persistence of ulcer symptoms during the
treatment. Resistance to antibiotics develops in some patients and
therapy fails to eradicate the infection in 20 percent of patients. Serious
side effects including fungal infections, diarrhea and
pseudomembraneous colitis occur in 30 percent of patients (Cuschieri,
1995).
Despite the large number of medical treatments, the recurrence rate
of ulcers treated non-operatively is on the order of 90% at 1 year,
regardless of which medication is used. Further, the widespread use of
these agents for the past ]0 years has not diminished the mortality due to
complications of ulcer disease, particularly in the elderly (Mouiel et al.,
1993). Although ulcer healing can be achieved in some 90 percent of
patients within 2 months of starting medication, almost 90 percent of
these patients will relapse by the end of t year of stopping treatment. Hr
receptor antagonists have presumably had no appreciable beneficial
effect on ulcer-associated mortality because immediately on stopping
treatment with these drugs, the acid output returns to pretreatment levels
and the ulcer diathesis still exists, leaving the elderly patient vulnerable

-67-
to the potentially fatal complications of perforation and bleeding
(Taylor, 1995). Duodenal ulcer has a natural cycle of healing and
relapse; and treatment by acid-inhibitory drugs, whether H2-receptor
antagonists or proton pump inhibitors, was effective only while they
were being taken, with a high relapse rate when they were stopped
(Johnson, 2000). It could be recommended, therefore, that those subjects
with a well-established ulcer diathesis who frequently relapse after
cessation of treatment with Hrreceptor antagonists should be considered
for elective peptic ulcer operation at approximately the age of 50 or
perhaps 60 years. Deferring elective ulcer treatment thereafter would
increase the postoperative mortality in view of the increased incidence of
coexisting medication problems, such as are encountered with therapy
for coronary artery disease, hypertension, respiratory disease and the risk
ofstroke (Taylor, 1995).
Surgery has been the mainstay for the management of
complications of peptic ulcer disease since the 1930s (Laws et al.,
1993). Although the incidence of elective surgery for peptic ulcer has
diminished dramatically in recent years, the number of operations for
bleeding or perforation has changed liitlc. Indeed, it has increased in the
elderly, many of whom are on NSAlDs and have no warning symptoms
before the complicarion arises (i.e., the complication is the first
presentation) (Chen, 1996).
The primary aim of any long-term treatment of peptic ulcer is; first,
to keep the ulcer healed to prevent life-threatening complications and,
second, to relieve symptoms (Johnson, 2000). The only established way
of maintaining ulcer healing is surgical repair of the ulcer (Jordan,
1989).

-68-
The other major consideration that will apply to the continued use
of peptic ulcer operations is one of cost In these increasingly cost­
conscious times where health care must he assessed in financial terms,
the alternative strategies of surgical therapy and drug therapy for ulcers
will have to be compared, taking into account financial considerations in
the long term. As operative treatment most commonly leads to life-long
healing of peptic ulceration and overcomes the risks of perforation or
bleeding from the ulcer, thus strategy may compare favorably to
prolonged or repeated use of drug therapy, which in itself is increasingly
expensive (Taylor, 1995).
The main indication for elective surgery now is true failure of drug
treatment, which takes two forms, the first is failure of the ulcer to heal
after 8 weeks of full-dose treatment with drugs and the second as an
alternative to long-term full-dose maintenance therapy with acid­
suppressing drugs. The patient should be given the choice of a lifetime of
drugs or an operation. This decision would depend on social factors, the
patient's age and temperament, and on economic factors In some
countries, poor patients cannot afford the drugs but can have an
operation free of charge (Johnson, 1995). Intractable pain, often
producing loss of sleep and social or economic dislocation, used to be
the major indication for elective surgical ulcer repair (Taylor, 1995).
Gastric outlet stenosis produced by aggressive duodenal ulceration
remams one of the absolute indications for surgical repair of ulcer
(Keynes, 1965). Medical treatment is unlikely to influence the fibrosed
duodenum, and so some form of therapeutic intervention is necessary
(Kreel et al., 19(5). A further remaining indication for surgical
treatment of ulcer is the aggressive posterior duodenal ulcer, which may

-69-
penetrate into the pancreas or posterior abdominal wall, sometimes
giving rise to pancreatitis or abscess formation. Under these
circumstances, healing is much more difficult to achieve with drug
therapy (Taylor, 1995). Perforation is an absolute indication for surgical
treatment in the early hours following its occurrence (Kay, 1978).
Operations for duodenal ulcer have ranged from radical forms of
gastric resection to the conservative highly selective vagotomy
(Donicott et at, 1978). The more aggressive the approach, in tenus of
acid reduction, the more likely is the ulcer to remain healed but at the
price of some undesirable and often incurable side effects such as
dumping and diarrhea. The more conservative the surgical procedure, the
less likely it is to have undesirable side effects; however, there is a
higher incidence of ulcer recurrence with the more conservative forms of
operation (Jordan, 1976).
In peptic-ulcer surgery there is a delicate balance between the
expedients of operative safety, simplicity and speed and the problems of
dumping, diarrhea, duodenogastric reflux, recurrent dyspepsia and death
(Taylor et al., 1982). Thus, there is a potential for major reduction in
ulcer-associated mortality by the carefuliy sei-cted application of
elective surgical repair of peptic ulcer (Taylor, 1995). The operation of
choice has progressively changed from gastroenterostomy to gastric
resection to some form of vagotomy alone or combined with a drainage
procedure (Laws et at, 1993).

-71-
patients to relieve the symptoms of gastric stasis. Later, Dragstedt
advocated the transabdominal, perihiatal approach to the vagal trunks,
followed by a pyloroplasty or gastroenterostomy. Since 1943, vagotomy
of some type has become a standard operation for DU (Johnson, 1995).
Virtually all operations for duodenal ulcer include some form of
vagotomy (Laws et at, 1993). Since its introduction more than 10 years
ago, parietal cell vagotomy has gradually become accepted as the
method of choice in the surgical treatment of chronic duodenal ulcer
mainly because of the well-documented low postoperative morbidity
(GrafTner et al., 1985). The fact that vagotomy heals duodenal ulcers by
reducing acid secretion is well known (J. Mouiel et aL, 1993).
Vagotomy fulfilled Dragstedt's aim of being a safe alternative to
gastrectomy; but it had a rather high recurrent ulcer rate, and some
patients still suffered from dumping syndrome, diarrhoea, and bile reflux
(Johnson, 20(0). Total truncal vagotomy leads to an almost total
reduction of gastric acid secretion., which is often accompanied by
pyloric spasm leading to gastric stasis (Moniel et aI., 1993). After
truncal vagotomy and gastroenterostomy early emptying of both liquids
and solids was increased and there was an overall increase in gastric
emptying over the 2-h period. Rapid gastric emptying may be
responsible, at least in part, for dumping and postvagotomy diarrhea; this
is particularly the case for the early phase of emptying where gastric
incontinence after vagotomy and drainage leads to the rapid emptying of
both liquids and solids emphasizing the importance of the pylorus in
controlling and monitoring gastric emptying (Caylor et aI., Aug. 1985).
A gastric drainage procedure subsequently becomes complicated by a

-72-
marginal ulcer which continues to require surgical intervention (Laws et
a1.,1993).
Proximal gastric vagotomy (PGV) is a modification of truncal
vagotomy, which was introduced by Dragstedt for the treatment of
duodenal ulcer (DU) in 1943. It is a technically demanding operation;
but when performed by an experienced surgeon, it is safe and gives a
cure rate for DlJ of more than 90%, with minimal side effects (Johnson,
2000). The main purpose of PGV is to avoid a pyloroplasty with its
attendant side effects (Johnson, 1995).
On the assumption that total vagotomy of the whole of the
derivatives of fore-gut and mid-gut was the main cause of the side
effects, a modification was devised by Griffith,(1960) in which only the
stomach was denervated, leaving the nerves to the liver and intestine
intact. This was named "selective vagotomy". However, because a
pyloroplasty or gastroenterostomy was still required, the side effects
remained (even if reduced to some extent), and this modification did not
become generally used. In the meantime, Holle et al. had devised an
even more selective operation in which the proximal part of the stomach,
which contained the parietal cells, was denervated, leaving the muscular
antrum, which is important for gastric emptying, still innervated.
However, they still performed a pyloroplasty, which was responsible for
some continued side effects (dumping and diarrhea) (Johnson, 2000).
Johnson (1970) in England and Amdrup (1978) in Denmark
completed the evolution of vagotomy by avoiding a drainage procedure
altogether. This operation was initially called "highly selective
vagotomy" to distinguish it from selective vagotomy, but other names
include "proximal gastric vagotomy" and "parietal cell vagotomy". The

I
I
I
I I
I
-73·
anatomic and physiologic bases were sound in that gall bladder
emptying, for example, is unaffected, but bile reflux into the stomach did
not differ regardless of whether there was a pyloroplasty (Eriksson et
aL,I990).
Proximal gastric vagotomy was more technically demanding than
truncal vagotomy and took longer to perform. The two challenges to the
surgeon are (I) to ensure that the relevant part of the stomach is
completely denervated and (2) that the junction between parietal cell
mass and muscular antrum is correctly identified so the antral muscle
remain innervated. The problem is that there is no visual demarcation
line (Johnson, 1981). In conventional highly selective vagotomy it is the
posterior parietal ceU mass. which is the most difficult area of the
stomach to denervate, particularly because of fibers at the
oesophagogastric junction and at the antral-corpus junction (T ylor et
aI., 1990) (fig, 8).
Fig. 8: Four areas are difficult to
denervate during proximal gastric
vagotomy. A: greater curve at
antrallbody junction; B: posterior
aspect of lesser curve; C:
posterior aspect of cardia; D:
supenor aspect of fundus
(Johnson, 2(00).

-74-
It has been largely as a result of ulcer recurrence rates that
operations for duodenal ulcer either stand or fall. Some recurrences are
inevitable and are treatable by drugs or further surgical procedures,
whereas the sequalae of dumping and diarrhoea are incurable.
Gastrojejunostomy was safe, simple and had few postoperative sequalae,
but floundered, almost half a century ago, on the grounds of high
recurrence rates. Rates of recurrence exceeding 25 percent, which have
been reported in the long term after highly selective vagotomy, have
aroused particular concern (Koffman et aI., 1983). These rates are
higher in the hands of the inexperienced surgeon (Blackett et aL, 1981).
In view of the high rate of late recurrence following HSV, some
surgeons extend the denervation lower on the lesser curvature, cutting
one or two of the branches of the crow's foot. Such an HSV, with
extensive mobilization of the cardia and esophagus creates the risk of
gastroesophageal reflux, whichrequirescorrection (Dubois, 2000).
Highly selective vagotomy is not without its disadvantages,
namely that the operation is tedious and time-consuming to perform,
damage to the nerve of Latarjet may produce gastric stasis and there is a
risk of ischaemic necrosis which, when it does occur, is not uncommonly
fatal. The major objection to highly selective vagotomy raised by
surgeons is that the operation is tedious and time-consuming, as every
nerve and blood vessel passing onto the lesser curve of the stomach,
above the incisura, hasto be ligated and divided (Taylor, 1979).
Elective peptic ulcer surgery has been affected not only by the
availability of the H2-receptor antagonists but also by concern relating to
the side-effects of truncal vagotomy and the high rates of recurrence
after highly selective vagotomy (Taylor et al., 1990). Highly selective

-75-
vagotomy may be associated with recurrence rates of less than 5%, but
rates of over 20% have been recorded in some series because of
inadequate denervation of the parietal cell mass (Taylor et al., 1982).
Consequently, the operation of conventional highly selective vagotomy
was somewhat slow to gain acceptance in many centers. Over the last
decade, it has become increasingly apparent that conventional highly
selective vagotomy in the hands of many surgeons is an unsatisfactory
procedure for chronic duodenal ulcer, largely because of ever-increasing
incidences of recurrent peptic ulceration. These are reported to be as
high as 30 per cent over follow-up periods of up to 18 years in the
excellent center in Copenhagen from which the operation was first
descnbed (Taylor, 1995).
Lesser curve seromyotomy was devised with the intention of
providing a simplified technique for denervating the parietal cell mass
(Taylor et at, 1982). The main advantage of lesser curve myotomy is
that it produces a highly selective vagotomy in an expeditiously and
easily performed manner. There should be neither risk of damage to the
nerve of Latarjet, which need not be identified, nor of ischaemic necrosis
ofthe lesser curvature (Tavlor; 1979).
In considering the structure and deposition of these branches of
the nerve of Latarjet that pass along the anterior and posterior walls of
the stomach and that innervate the parietal cell mass, there are three
anatomic points of fundamental importance. First, there is no particular
predilection for these nerves to run with blood vessels along the lesser
curvature of the stomach. Second, the nerves can be traced for some
distance beneath the serous coat before they penetrate the gastric
musculature. Third, the vagus nerve branches always run superficial to,

-76-
and more obliquely than the blood vessels along the lesser- curvature of
the stomach. A fourth anatomic point worthy of consideration is that the
main nerve of Laterjet often bifurcates, or even trifurcates, very high
along the lesser curvature of the stomach and well proximal to the classic
position ofthe CTOW'S foot at the incisura angularis (Fig. 9).
Fig. 9: Anatomic relationship of the nerve of Latarjet, which lies
superficial to the left gastric vessels. There is no particular predilection
for the branches of the nerve of Latarjet to run with the vessels (Taylor,
1995).
Applying these anatomic considerations, lesser curvature seromyotomy
was devised. In this operation, the branches of the nerve of Latarjet are
divided as they run intimately welded to the serosa close to the lesser
curvature of the stomach . Division of the longitudinal and superficial
circular muscle fibers produces wide separation of the divided nerve
\ "'i

-77-
bundles. The blood vessels running across the lesser curvature onto the
anterior wall of the stomach are divided, but those that form the end
arteries directly entering the lesser curvature are preserved, thus
overcoming any possibility of ischemic necrosis of the lesser curvature
of the stomach. This complication, which accounts for the major
mortality associated with conventional highly selective vagotomy, has
not been recorded after ASPTV in several thousand cases (Taylor,
1995).
Following vagotomy, intragastric pressure after a meal is increased.
It is possible that by virtue of dividing the full thickness of the circular
muscle of the corpus of the stomach in performing seromyotomy the loss
of accommodation for a meal is to some extent compensated and that
rapid early emptying does not occur. If this was true, not only should
dumping and diarrhoea be reduced but also distension or epigastric
fullness, present in up to 50 per cent of patients after vagotomy, should
be less or absent. This would provide seromyotomy with a potential
advantage over all existing forms of vagotomy including the
conventional highlyselected procedure (Taylor et al, Aug. 1985)_
Initially in humans, the seromyotomy was performed ?long both
anterior and posterior walls of the stomach (Taylor, 1995). Although
this operation is quick and easy to carry out, the posterior wall of the
stomach is less accessible and therefore more difficult to denervate, in
particular close to the gastro-oesophageal junction (Taylor et al., 1982).
After performing some of these procedures, the author decided to modify
the operation and carry out anterior lesser curvature seromyotomy with
posterior truncal vagotomy. The reasons for this were again technical.
Experience soon showed that the addition of posterior trucal vagotomy

-78-
to anterior lesser curvature seromyotomy did not appreciably increase
the incidence of diarrhea when compared to highly selective vagotomy,
and dumping did not occur (Taylor, 1995).
Two major anatomical considerations are fundamental to the
success of this procedure. First, that all vagal branches passing to the
parietal cell area are divided and, secondly, that the divided nerves do
not regenerate (Taylor, 1979). Anterior vagotomy is rapidly and easily
performed by means of a seromyotomy paralleling the lesser curvature
from the gastroesophageal junction to the crow's foot (Moniel et al.,
1993). Division of the posterior vagus nerve trunk should reliably
denervate the whole of the posterior wall of the stomach and thus
overcome the propensity of some surgeons to leave intact areas of
innervation of the posterior wall of the stomach at the esophagogastric
junction and the antral-corpus junction. Retaining innervation of these
two areas probably accounted tor a large number of recurrent ulcers that
developed after this operation and may have facilitated reinnervation of
the posterior wall of the stomach, which might have occurred by
sprouting from the intact residual nerves (Taylor, 1995).
Three factors may contribute to the dumping and diarrhea produced
after truncal vagotomy and drainage These are (1) division of the
hepatic branches of the anterior vagus, (2) division of the celiac branches
of the posterior vagus, and (3) destruction of the pylorus by pyloroplasty.
Of these, the latter would appear to be the most significant contributory
factor to emptying problems following vagotomy. Clearly, the pylorus is
controlled by a very intricate system of innervation that permits the
emptying of liquefied gastric contents into the duodenum in a highly
controlled and sophisticated way. Most of the innervation of the antrum

-79-
and pylorus is afferent rather than efferent, and these afferent nerves
probably coordinate the mechanism of gastric emptying. Clearly,
division of the celiac branches of the posterior vagus nerve may
contribute in part to post-vagotomy sequelae but, when the integrity of
the pylorus and of the hepatic branches of anterior vagus are maintained,
as in the operation of ASPTV, then it is unlikely that division of the
celiac branches of the vagus will produce any significant clinical
problems. Preservation of the pylorus could be justified from the
observations of Daniel et at, (1973), who showed that stimulation of the
anterior nerve of Latarjet produced contraction of the circular muscle in
the anterior and posterior antral walls, the stimulus being conducted
through vasovagal arcs to the posterior wall of the stomach (Taylor,
1995). Following vagotomy, intragastric pressure after a meal is
increased. It is possible that by Y; ..rtue of dividing the full thickness of the
circular muscle of the corpus of the stomach in performing seromyotomy
the loss of accommodation for a meal is to some extent compensated and
that rapid early emptying does not occur. If this was true, not only should
dumping and diarrhoea be reduced but also distension or epigastric
fullness, present in up to 50 per cent of patients after vagotomy, should
be less or absent This would provide seromyotomy with a potential
advantage over all exrstmg forms of vagotomy including the
conventional highly selected procedure (Taylor et al., 1985).
Anterior seromyotomy with posterior truncal vagotomy represent a
greater degree of gastric denervation than highly selective vagotomy, the
whole of the posterior wall of the stomach being denervated. This may
obviate the risk of leaving areas of the parietal cell mass, at the antral­
corpus and gastro-oesophageal junctions innervated (Taylor et al., Dec.

-80-
1985). We suggest that the expedients of peptic-ulcer surgery are that the
parietal cell mass must be denervated; the pylorus should be preserved;
gastric emptying should be near normal; the loss of adaptive relaxation
should be compensated for; duodenogastric reflux should be minimised;
the incidence of dumping and diarrhoea must be low, the operation must
be safe, simple, and rapid; risks of ishaemic necrosis and of damage to
the nerve of Latarjet must be overcome; the incidence of recurrent ulcer
must be acceptably and competitively, in terms of other operations, low.
The operation of anterior lesser curve seromyotomy with posterior
truncal vagotomy appears to fulfill many of these expedients (Taylor,
1982).
Apparently, the major cause of death after conventional highly
selective vagotomy was ischemic necrosis of the lesser curvature, yet
this complication has never been reported after ASPTV Preservation of
the left gastric vessels to the posterior wall of the stomach and also of
those end arteries that directly enter the lesser curvature would seem to
obviate any potential risk that exists for ischemic necrosis (Taylor,
1995).
We have, in recent years, been performing the operation of anterior
lesser curve seromyotomy with posterior truncal vagotomy (ASPTV)_
The operation is quick and simple to perform and denervates the parietal
cell mass with the whole posterior wall of the stomach whilst obviating
the need for a drainage procedure (Taylor et al., Aug. 1985). Such is the
relative simplicity of anterior seromyotomy with posterior truncal
vagotomy that the operation takes no longer to perform than truncal
vagotomy and pyloroplasty, thus keeping the nonspecific risks of surgery

-81-
to a minimum. In our own center the average total operating time is 40
min (Taylor et at, Dec. 1985).
The one complication directly attributable to the operation, that of
gastric perforation, was considered to be due to a diathermy bum.
Initially the muscle fibers were divided by diathermy; the use of
diathermy is now confined to the incision m the serosa and the
coagulation of small vessels running along the serosal surface, the
muscle fibers are divided by blunt-ended dissecting scissors. The
integrity of the mucosa is checked at the end of the operation by
introducing air into the stomach and it is currently considered that the
risk of perforation is entirely avoidable. The operation carries with it all
the advantages associated with preservation of the innervated pylorus,
the value of which has been shown with conventional highly selective
vagotomy (Taylor, 1979). ASPTV was technically simpler and less
time-consuming than conventional PGV, it would replace the latter
procedure as the operation of choice in the surgical treatment of chronic
duodenal ulcer (Taylor, 1995).
Since the rnid-1985s, minimally invasive procedures and
technology have changed the pattern of surgical thinking and patient care
and, particularly with the introduction of laparoscopy into the practice of
general surgeons, a revolution in surgical techniques and technology has
occurred (MacFadyen, 1999). The last decade of the twentieth century
probably will historically be high lighted as the period in which the
widespread use of laparoscopic intra-abdominal surgery was shown to be
feasibleand often advantageous (Taylor, 1995).
There is no question that minimal access (also called minimally
invasive) surgery has revolutionized the practice of many surgical

-82-
disciplines. The shorter postoperative stay, decreased pain and
discomfort, and faster return to daily activities are the most significant
positive factors in its acceptance (Herd et at., 2000). The postoperative
measures required after laparoscopic vagotomy are minimal (Dubois,
2000). Laparoscopic procedures have begun to replace many
conventional operations because of the avoidance of major surgery and
the rapid recovery of the patient. The majority of these traditional
operations will be performed laparoscopically in the future (Cuschieri,
1992). The laparoscopic approach to conventional surgery is a
burgeoning area of surgical practice, with new techniques and
procedures introduced on a yearly if not monthly basis. This revolution
has been fueled by the belief among surgeons, referring physicians, and
the general public that laparoscopic procedures are "minimally invasive"
and thus entail less pain (compared to traditional open surgery) and lead
to a faster recovery (Velanovich, 2000).
The laparoscopic approach is now a standard alternative option In
abdominalsurgery (Lee et aI., 1999).
One important factor that may relate to the use of surgical
procedures is the duration of hospitalization and the period of time lost
from active employment: an associated issue is the feasibility and
increasing use of laparoscopic surgery. With the latter, inpatient times
have fallen to 1-2 days, and periods lost from active employment are as
brief as 2 weeks (Taylor, 1995).
Laparoscopic management of duodenal ulcers is feasible. The
various forms of vagotomy, omentopexy, and drainage procedures arc
technically feasible VIa laparoscopic approach. The laparoscopic

-84-
are laid out for traditional surgery should laparotomy be necessary
(Mouiel et at, 1993).
Pneumoperitoneum and Trocar Insertion:
The pneumoperitoneum is created by insufflation of C02 and a
pressure of 14 mmHg is maintained electronically. The puncture needle
is usually introduced through the umbilicus. Once the abdominal wall is
raised offthe viscera troears are introduced (Mouiel et al., 1993).
Basic Laparoscopic Techniques:
Exploration:
The abdominal cavity is explored as soon as the video-laparoscpe is
inserted. The surgeon should ascertain that the operation is feasible and
particularly that the liver can be retracted so the area of operation is
visible. If the operation is impossible or seems dangerous or difficult,
open surgery is preferred (Moniel et aI., 1993).
Dissection, Hemostasis, Tissue Approximation:
As with open surgery, dissection may be "sharp", usmg scissors,
the spatula, or the hook with or without electrocautery; or it may be
"blunt", using a probe or pledget swabs. For hemostasis, several methods
arc used: (1) the hook coagulator is used with monopolar current to
coagulate small-caliber vessels (2) the neodymium laser coagulates
superficial surfaces with a contact fiber (3) Titanium clips are used for
the short gastric, left gastric, and small accessory hepatic vessels after

Approack to the Hiatus:
-86-
The left lobe of the liver is retracted using a palpation probe placed
through the xiphoid port. The pars flaccida is seized with grasping
forceps, and the surgeon incises it with the hook coagulator and enters
the lesser sac. The dissection is continued up to the right crus of the
diaphragm. A coronary hepatic vein or accessory left hepatic artery may
be encountered and must be divided between two clips (Mouiel et al.,
1993).
Posterior Truncal Vagowmy:
The two primary landmarks during performance of a posterior
truncal vagotomy are the caudate lobe of the liver and the right crus of
the diaphragm. The right crus is seized with the right-sided grasping
forceps and retracted to the right to expose the pre-esophageal
peritoneum. The peritoneum is incised along the length of the border of
the right crus, allowing separation of the abdominal esophagus anteriorly
and to the left, giving access to its posterior wall and mesoesophagus.
Within the depths of this angle the posterior vagus can be easily
recognized as a pearly white cord. It is gently grasped with a forceps
while its vasa vasorum is stripped with the hook coagulator. The nerve is
then transected between two clips (Mouiel et al., 1993) (Fig. 10).

-87-
... --- -- .-
Fig. 10. Posterior truncal vagotomy with the two essential landmarks:
right diaphragmatic crus and caudate lobe of the liver (Mould et sl.,
1991).
Anterior Seromyotomy:
The anterior surface of the stomach is stretched with the right and
left grasping forceps. The outline of the seromyotomy is marked with the
hook coagulator, beginning exactly I.5cm from the lesser curvature at
the level of the gastroesophageal junction, and this distance is
maintained paralleling the lesser curvature and stopping 5 to 7cm from
t- the pylorus at the level of the trifurcation of the "crew's foot", respecting
the integrity of the two inferior branches. The seromyotomy is performed
with the electric hook coagulator using a blended monopolar current at a
setting of medium wattage. The hook successively cuts through the
serosa, the oblique muscular layers, and the superficial circular muscular
layers. The two grasping forceps hold the edges, helping stretch the deep

-88-
circular fibers, which eventually split as a result of the combined effect
of mechanical traction and hook coagulation. After these last muscular
fibers are split, the bluish mucosa protrudes, and it is possible to verify
its integrity because of the magnification produced by the video­
laparoscope, as during microsurgery. The seromyotomy is continued
proximally in the same fashion. During this part of the procedure one
may encounter three to five short vessels, and they should be transeeted
after hemostasis. Several approaches can be used: As described by
Taylor,(1979), the vessels can be isolated in the seromuscularis by
passing a hook underneath them and clipping and transecting them;
alternatively, one can use sutures. It is essential to observe rigorously all
the details of the exact anatomic location of the seromyotomy and
hemostasis; otherwise, the seromyotomy may be ineffective. Once the
seromyotomy is achieved, it appears as a slice 7 to 8mm wide (Fig. II).
/
)
I
/
,.
,I
Fig. 11 . Anterior lesser curve seromyotomy (Mouiel et aL, 1993).
....
,

-90-
In our expenence, this laparoscopic procedure has given the same
results as open surgery without mortality and with low morbidity.
Operative time has ranged from 55 to 190 minutes, with a mean of 90
minutes. The postoperative period has been relatively benign. Pain is
generally trivial and is due to minimal parietal trauma and the use of
local anaesthetic infilteration around the abdominal puncture points;
systemic analgesics are unnecessary. The patients are ambulatory much
earlier than after laparotomy owing to the lack of invasive postoperative
care. A nasogastric tube is left in place for 24 hours, and oral fluids are
resumed after its removal. The patient is discharged between the 3 m and
5 th postoperative days and this period possibly may be shortened further
(Mouiel et al., 1993). The postoperative course is usually surprisingly
uneventful. The hospital stay varies from 3 to 5 days (Dubois, 2000).
During follow-up of the laparoscopic Taylor procedure, no clinically
significant bloating, diarrhea, or dumping has been observed.
Postoperative upper endoscopy proved to heal the duodenal ulcer
completely. No recurrence has been observed (Mouiel et al., 1993).
There is good evidence that the success of POY (or any type of
vagotomy) depends on the completeness of the denervation of the
parietal cells. The problem is that the fine vagal branches arc hardly
visible, and the area of the gastric parietal cell mass can not be seen by
looking at the outside of the stomach. The vagus nerve, as its name
implies, is variable (Johnson, 2000). There is an understandable desire
to have a test that will tell the surgeon that the vagotomy is incomplete
during the operation, when faults can be corrected. It is of little comfort
to discover the incompleteness 10 days to 3 months postoperatively. Two
groups of tests have been devised, one based on motility and the other on

-91-
acid secretion. They can be used for all types of vagotomy. In the
Burge,(1958) test, the rise in intragastric pressure is measured, using a
nasogastric tube, in response to stimulation around the vagal trunks with
an electric current If there are no residual vagal fibers supplying the
stomach, there will be no rise III pressure [Johnson, 1995).
Grassi,(1971) test uses a pH probe inserted in the stomach through a
gastrostomy after the surface of the stomach had been washed with
saline. Donahue,(1985) Congo red test sprays the mucosal surface with
Congo red dye, which turns black in acidic areas and can be viewed with
a gastroscope at the operation without opening the stomach. Both tests
depend on the physiologic phenomenon that the parietal cells becomes
temporarily completely unresponsive to a circulating gastrum (.Johnson,
2000). The intraoperative Congo red test has much appeal and we intend
to incorporate it in our operations (Laws et al., 1993). Demonstrating the
adequacy of a vagotomy by the endoscopic Congo fed avoids the futile
effort of completing an incomplete but adequate vagotomy and indicates
the need for other measures (Griffith, 1995) (Images 1,2).

-92-
Image (1): Black color change along the greater curvature suggesting
persisting vagal innervation despite completion of the standard
dissection during PGV (Donahue et aI., 1987).
Image (2): Disappearance of the black color change along the greater
curvature after division of the right gastroepiploic nerve (Donahue et
al., 1987).

,..--;.,
i /j;
'Ii
I/ i
, r
'.../)
/..-.--)

PATIENTS:
-93-
PATIENTS AND METHODS
This work was conducted in the Department of General Surgery at
Faculty of Medicine in Zagazig University and in the Center of Digestive
System Surgery at Faculty of Medicine in Mansoura University. It was
applied to 20 patients from the received 30 ones suffering from chronic
duodenal ulcer disease.
Patients asked for surgery because they could economically not
tolerate the long periods of the expensive medical treatment which gave no
permanent cure and relapses often occurred on stopping it, others because
they got exhausted and afraid from the multiple attacks of haernatemesis and
melena and others from the severe epigastric pain which could not be
prevented by medical treatment.
All patients were subjected to the following
1- Full history taking.
2- FuJI general and local examination.
3- Routine investigations such as urine analysis, stool examination,
hematological tests, plain chest x-ray and abdominal ultrasonography.

-94-
4- Specific investigations such as fibrooptic upper GI endoscopy (Image 3)
and barium meal (Image 4}
5- Upper GI endoscopy of the received 30 patients revealed 7 patients were
found suffering from marked pyloric stenosis and 3 from pyloric
obstruction; all were excluded as contraindication to our procedure and
bilateral truncal vagotomy with gastrojejunostomy was applied to them.
6- Laparoscopic anterior seromyotomy with posterior truncal vagotomy
assessed by intraoperative endoscopic Congo red test was applied to 10 of
the remaining 20 patients and laparoscopic anterior seromyotomy with
posterior truncal vagotomy alone was applied to the other 10 ones.
7- The Hrreceptor antagonists and the PPIs therapy were stopped for 48 hrs
before surgery to prevent interference with the Congo red test in the
Congo red test group.
8- Patients were reviewed after the first month and each three months after
the operation. Questions were specifically asked a proforma regarding
general well-being, pain, dyspepsia symptoms, dumping, vomiting and
diarrhea, with special attention to symptoms suggestive of recurrent ulcer
disease. Upper GJ endoscopy was performed when symptoms of recurrent
ulcer were present, and only when an ulcer crater was endoscopically
verified was the patient classified as having a recurrent ulcer. A recurrent
ulcer was defined as an endoscopically proven, symptomatic relapse.
9- The results offollow up were recorded and analysed.

METHODS:
Preparation:
-95-
General anesthesia with endotracheal intubation and intra-operative
monitoring was used. A nasogastric tube attached to a continuous very low
suction was used to maintain complete deflation of the stomach. The patient
was prepared and draped; and instruments were laid out for traditional open
surgery should laparotomy might be necessary.
Position:
The operation was performed with the patient in the supine position
with legs spread apart. The operating table should allow 15° elevation
(reverse Trendelenburg position). We place a small support between the
shoulder blades to elevate them approximately 1Ocrn.
The operating surgeon stranded between the patient's legs. The first
assistant was on the patient's left and the second assistant on the right. The
video-endoscopic system with irrigation-suction were placed on the left A
second video monitor was placed on the right, with the electrocoagulation
unit
Instrumentation:
The standard instruments required for laparoscopic surgery were used.
We routinely used a bipolar coagulating knife or an electro-surgical hook
knife with a channel for smoke evacuation, a curved electro-coagulating

-97-
performed laparoscopically. When difficulties were anticipated, open surgery
was performed.
Operative Technique:
The procedure involved three steps: A) access to the hiatal region, B)
posterior truncal vagotomy, and C) anterior seromyoromy.
A- Acce.u to the hiatus:
The left lobe of the liver was elevated with the help of the retractor
(Image 5) and the surgeon gained access to the hiatal region by opening the
lesser omentum (Image 6), which was stretched between two retracting
dissectors at the level of the right crus of the diaphragm. Ibis division gave
access to the upper part of the lesser sac, while respecting the gastrohepatic
branches of the anterior vagus nerve. The incision was continued to the
region ofthe right crus and was mobilized along its entire length.
B- Posterior truncal vagotomy:
The two landmarks for posterior truncal vagotomy are the caudate
lobe of the liver on one side and the right crus of the diaphragm on the other
(Image 7)_ The right crus was grasped by a dissector and drawn towards the
right to expose the pre-esophageal peritoneum. Incision of the peritoneum
along the border of the right crus provided access to the posterior aspect of
the esophagus and the mesoesophagus where the abdominal esophagus could
be tracted outwards.

-98-
The white trunk of the posterior vagus nerve could easily be identified
in this angle. The vagus was grasped by a dissector held taut (Image 8) and
cleared ofany associated small vessels with electrocoagulating hook knife. A
segment was resected between two clips (Image 9, I 0)
c-Anterior seromyotomy:
The anterior wall of the stomach was displayed with the help of
graspers inserted through the right and left subcostal ports
Three to five short vessels were encountered along the line of
dissection. These vessels were divided between ligatures (Image II).
Extreme care was taken to achieve adequate hemostasis during
seromyotomy.
The position of the seromyotorny was marked out with the coagulating
hook (Image 12), from the esophagogastric j unction which is the upper limit
of seromyotomy (Image 13) following the lesser curvature of the stomach at
a distance of 1.5 em and this distance was maintained parallel to it and
stopping about 6 em from the pylorus at the level of the trifurcation of the
"crew's foot", which is the lower limit of scrornyotomy (Image 14),
respecting the integrity of the two inferior branches.
Seromyotorny was performed using bipolar coagulation knife (Image
15) or coagulating hook (Image 16) starting from below (Image 17); the
coagulating knife was used to successively incise the serosa, the oblique and
circular muscle layers The two graspers were used to hold the edges of the
incision, improving exposure of the deep circular muscle fibers which were

Image (3): Large deep
active anterior superior
duodenal ulcer revealed
during preoperative
upper GI endoscopy.
Image (4): Preoperative
barium meal revealing
deformed duodenal cap.
-101-

Li er
-102-
Image (5): Elevation of the liver using a fan-shaped liver retractor.
Image (6): Opening the lesser omentum to gain access to the hiatal
region.

-103-
c
l
Image (7): The caudate lobe of the liver and the right crus of the
diaphragm; the two landmarks for posterior truncal vaqotorny.
Image (8): Traction of the white trunk of the posterior vagus nerve.

-104-
Image (9): Clipping of the posterior vagus trunk.
Image (10): A segment of the posterior vagus trunk resected between
two dips.

-105-
Image (11): The angle of His, at the esophaqoqastnc junction, the
upper limit of the anterior seromyotomy.
Image (12): The crow's foot, the lower limit of the anterior
seromyotomy.

-106-
Image (13): Ligation of the big vessels running onto the anterior aspect
of the stomach.
Image (14): Marking the line of anterior seromyotomy using coagulating
hook.

-107-
Image (15): Starting anterior seromyotomy from below upward, at the
level of the proximal branch of the crow's foot.
Image (16): Anterior seromyotomy using bipolar coagulating knife.

-108-
Image (17): Anterior seromyotomy using coagulating hook.
Image (18): Suturing the anterior seromyotomy in an overtapping
manner.

-109-
Image (19): Chronic duodenal ulcer revealed during intraoperative
endoscopic Congo red test.
Image (20): Gastric outlet patency revealed during intraoperative
endoscopic Congo red test.

Image (21): Washing the gastric
mucosa with water during
intraoperative endoscopic Congo
red test.
Image (22): Spraying the gastric
mucosa with the Congo red
solution during the intraoperative
endoscopic Congo red test.
Image (23): The gastric mucosa
free of black spots after spraying
with Congo red solution during the
intraoperative endoscopic Congo
red test.
-110-

_.- -1
1
1
1
1
1
1
1

-112-
Two patients were converted to the open procedure; one of them
due to perforation of the gastric mucosa with diathermy and the other
was due to difficult dissection at the hiatal region.
In the Congo red test group, nine patients showed grade I and one
showed grade II. No patients had showed grade 1Ilor IV
The operating time, i.e. time passed from induction of anesthesia to
return of the patient to the recovery room, for laparoscopic ASPTV
ranged from 70 to 80 minutes with mean of 75 minutes. The
intraoperative endoscopic Congo red test increased the operative time
with only 5 to 7 minutes with a mean of6 minutes (tables 8-9) (Fig. 16).
Operative mortality, defined as death occurring during surgery or
the subsequent 30 days, did not occur at any patient. The only
intraoperative complication, related to the procedure, was the perforation
of the gastric mucosa at one patient. Significant immediate postoperative
complications did not occur.
days.
The hospital stay for the laparoscopic ASPTV ranged from 3 to 4
Symptoms were classified as: absent, mild or severe. A side effect
was considered severe if it interfered with the patient's life or
necessitated repeated medication. Patients with diarrhea were classified
according to the frequency of the attacks either with frequent diarrhea or
with infrequent diarrhea.
The patients were graded I-IV on a Goligher, (1978) modified
Visick classification. According to this classification, patients without
recurrence symptoms were classified as Visick grade T, those with mild

-114-
Table 3: The received patients presented with complication ofch.D.U
Complication No. %
Haematemesis and meleana 8 26.66
Pyloric obstruction 3 10
Marked pyloric stenosis 7 23.3
Ulcer perforation 0 0
Total No. ofthe received cases 30 100
Ulcer perforation
Marked pyloric
stenosis
Pyloric
obstruction
Haematemesls
and meleana
I
I
U
o 5 10 15 20 25 30
Fig. (13): Distribution ofthe received patients presented with
complication ofch.D.U
u
u

-115-
Table 4: The excluded and the operated cases.
Cases No. %
Excluded cases:
•
Due to marked pyloric stenosis 7 23.3
.
• Due to pyloric obstruction 3 10
Operated cases:
• ASPTValone 10 33.3
• ASPTV with ECRT 10 33.3
Total No. ofthe received cases 30 100
33.3%
10.0%
Fig. (14) : The excluded and the operated cases
Due to mM'ked pyloric stenosls
iJ Due to pyloric obstruction
u ASPTV alone
o ASPTV with ECRT

-119-
Table 8: Timing ofthe operation
Step Time (min)
Induction ofanaesthesia 0.0
Trapping 5
Insertion ofports 5
Exploration and liver elevation 2
Annroach to the hiatus 2
PTV 10
Anterior seromvotomv 30
Congo red test 6
Suturing; 10
Waldng; 5
Total 75
Waking
Suturing
Congo red test
Anterior seromyotomy
PTV
Approach to the hiatus
Exploration and liver elevation
Insertion of ports
Trapping
Induction of anaesthesia
0
=:J
"1
j
I
I
I
I
o 5 10 15 20 25 30 35
Fig. (18): Timing ofthe operation
I

-122-
m 1987 when laparoscopic cholecystectomy was first performed; and
subsequently, minimal-access approaches have been used by general
surgeons for multiple intra-abdominal operations, and that minimally
invasive surgery revolutionized the practice of general surgery in the
past decade. Lee et at, (1999) mentioned that the laparoscopic approach
is now a standard alternative option in abdominal surgery. Kathouda
and MouieJ(1991) were the first who applied the laparoscopic approach
to chronic duodenal ulcer disease.
In our study we evaluated the results of anterior seromyotomy with
posterior truncal vagotomy as a surgical treatment for chronic duodenal
ulcer disease. Along the last two years we received 30 patients with
chronic duodenal ulcers, 20 males and 10 females with MIF ratio equals
2/1 which is the same as estimated by Christopher et al., (1995), and
this may be due to the fact the men usually have more active nervous life
style with higher rates ofsmoking and drinking than women.
The age of the patients ranged from 18 to 7() with a mean of 44
years which corresponds Langman, (1974) range; 20 patients were
heavy smokers and all of them were below the age of 60 years while 6
ones were on NSAlDs and were below the age of 60 years; both smoking
and NSAIDs are, as Johnson, (2000)said, factors which predispose to
DO.
All patients asked surgical treatment after trying vanous types of
medical ones especially after being informed about the benefits and
advantages of the laparoscopic surgery. All of them complained of being
tired and exhausted from the repeated relapses of the disease which

-123-
reached 10 times for 22 of them, and 8 patients were afraid from the
recurrent attacks ofhaematemesis which reached 5 times for 6 ofthem.
We depend mainly in our diagnosis of chronic duodenal ulcer, as
Taylor et at, (1982), Christopher et al., (1995) and Mouiel et
al.,(1999) did, on preoperative upper GI endoscopy and barium meal
test. Upper GI endoscopy revealed 7 cases of marked pyloric stenosis
and 3 cases of pyloric obstruction and all of them were excluded as
contraindications to ASPTV and bilateral truncal vagotomy wit h
gastrojejunostomy was applied to them. Fourteen of the remaining 20
cases showed single I"" part DU, 2 cases showed two kissing 1!l part DU
and the last 4 cases showed single 1"" part DU; all ulcers varied from 0.5
to l.Scm in size.
This study included the last 20 patients, 10 of them underwent
laparoscopic ASPTV alone, while the other 10 underwent laparoscopic
ASPTV assessed by intraoperative ECRT.
We preferred to perform the operation with the patient in the supine
position with legs apart and thc operating surgeon standing between his
or her legs which is the same position used by Mouiel et 1\1., (1993)
because it is more accessing and comfortable for the surgeon and avoids
pressure ischaemia of the patient's legs which occurs in the French
preferred position described by Dubois,(2000) in which the patient lies
in the lithotomy position with the operating surgeon standing between
his or her legs resting his arms on the legs.
We applied the technique applied by Mouiel et al.,(1991) with mild
differences. In ]0 cases we placed a liver retractor port about I" below
the xiphoid process, and in the other ones we placed it below the right

-124-
costal margin. Also we used a fan-shaped liver retractor instead of
MOllie' et al.,(1993) palpation probe and we found it more accessible,
stable and easily handled when placed in the subxiphoid port
In the FeRT group we used the second monitor to connect it with
the gastroscope to follow and evaluate the test
Access to the hiatus and P'TV were so simple and fast the same as
reported by both Taylor et al., (1979) and Mouiel et al., (1991), except
in one patient who showed difficult dissection at the hiatal region due to
vague anatomy which led to turn him to open surgery.
To transect the large vessels on the anterior gastric wall Taylor et
al., (1979) and Mouiel et at, (1993) used clipping before cutting them,
but preferred to use ligation with sutures because ligatures are more
secure and stable than clips which may slip during gastric contractions.
For seromyotomy Mouiel et al.,(t993) used rnonopolar coagulation
hook, while we used the monopolar coagulation hook, the bipolar
coagulation knife and the harmonic ultrasonic knife. We found the latter
two knives, especiaJly the last one, more easy, fast and safe than the
former and the case of mucosal perforation happened during using the
former.
For the overlapping closure of the serornyotomy wound we.as
Mouiel et al., (1993) and Taylor. (1995) did, preferred the continuous
suture than the interrupted one because it is more secure, coapting, easy,
rapid and close any unnoticed perforation ofthe gastric mucosa.
Kusakari et al., (1972) and Saik et al., (1976) used HistaJog 50mg
subcutaneously to stimulate maximum gastric acid secretion during

-125-
intraoperative ECRT , Donahue et al., (1987) used both histalog and
pentagastrin 6uglkg subcutaneously and Chisholm et at, (1993) used
pentagastrin, but we used insulin 0.2 i.u./kg intravenously because of the
unavailability of the previous substances and to avoid their hazards
especially hypotension and shock and we found it giving the required
response beside its easy availability
In the intraoperative EeRT group, 9 patients showed G I tests, 1
Patient G II test and no patients showed G lIT or G IV tests.
As Chisholm et al., (1993) did we found the intraoperative ECRT,
IS easy to perform, does not require specialized equipment. It added
little to the operating time. We completed it in about 6 minutes, near the
time consumed by Donahue et al., (1987) who completed it in less than
5 minutes It was very beneficial as it revealed the degree of
completeness of vagotomy while we were in situ and able to complete it
if it was not complete and so ensuring a great guarantee against post­
operative recurrence. So we recommend the intraoperative endoscopic
Congo red test to be an essential step oflaparoscopic ASPTV
This study revealed that the laparoscopic ASPTV is simple and fast
technique. The operating time ranged from 70-80 minutes with a mean
of 75 minutes which is shorter than that achieved by Mouiel et
al.(I993), who recorded a mean operating time of90 minutes.
The only one intra-operative complication related to the procedure,
reported also by Taylor, (1979), was perforation of the gastric mucosa,
due to burning with the electrocoagulation hook used to perform
seromyotomy and we could avoid it by USIng a bipolar
electrocoagulating knife scromyotomy.

-126-
Mouiel et al., (1993) were not forced to convert a laparoscopic
procedure to a laparotomy while we did this in 2 cases, one due to
difficult dissection at the hiatal region and the other due to perforation of
the gastrie mucosa.
We had no cases of operative death unlike Mouiel et al., (1993)
who reported one operative death due to myocardial infarction, which is
a cause away from the procedure.
Mouiel et at, (1999) reported one case of postoperative
pneumothorax treated by a chest drain for 24 hours, while we had one
patient complained of early dysphagia which disappeared spontaneously.
He was that patient with difficult dissection at the hiatal region; so early
dysphagia may be due to excessive manipulation at this region.
Otherwise the post-operative course showed no significant complications
and was very eventful.
Tay.or,(1995) reported a hospital stay which may fall to 1-2 days,
while Mouiel et al., (1993) and Dubois. (2000) had a hospital stay
vaned from 3 to 5 days, but in our study the hospital stay ranged from 3
to 4 days
During follow up Taylor et at. (1982) reported no severe
postvagotomy diarrhea but only mild transient increases in bowel action,
while Moniel et al., (1999) had one case of reflux esophagitis and 2/62
cases of ulcer recurrence after 2 years and Oostvogel et al., (1988) had
4/46 cases of recurrence after :::6 months During our follow up, which
reaches 2years, no mortality occurred, no significant bloating or
dumping were recorded and only one patient had infrequent diarrhea
...

-127-
which was successfully treated medically. We had no recurrence cases
i.e 0120 cases,
We had no cases of ischemic necrosis of the lesser curvature, the
same as Taylor,(1995). Mouiel et al., (1999) did
According to Visick grading, after 2-4 years follow up of 143
patients, Taylor et al., (1982) had 81 patients G I, 53 patients G II, 7
patients G III and 2 Patients G IV, Taylor et at. «1990) after 2 years
follow up of 76 patients had 52 patients G I, 14 patients G II, 5 Patients
G HI and 5 patients G IV while our 2 years follow up of 20 patients
revealed 17 patients G I, 3 patients G II and no patients as G IV
Lastly after this study, we agree with Cuschieri, (1992), Laws ct
al., (1993),Taylor.(1995). Mouiel et al., (1999) and Leena et al., (2002)
that a minimally invasive technique such as ASPTV, especially when
assessed by intra-operative endoscopic Congo red test, is a safe speed
economic and surely curing alternative to the life-long expensive not
safe and not surely curing medical treatment

-128-
SUMMARY AND CONCLlJSJ()N
Chronic duodenal ulcer disease is a common disease nowadays and
although benign, it causes a high rate of mortality which equals that of
some dangerous diseases such as pancreatic and esophageal carcinomas.
So there is a continuous need for a successful treatment for this disease.
Many types of treatment either surgical or medical were devised in this
way and they vary in either givmg high curing rates but with high
mortality and complications rates, or gIvmg low mortality and
complications rates but with low curing and high recurrence rates.
OUf study, which included 20 patients with chronic DU, ASPTV
alone was applied to 10 of them and ASPTV assessed by intraoperative
ECRT was applied to the other 10 patients, revealed that laparoscopic
anterior seromyotomy with posterior truncal vagotomy, which was first
introduced by Taylor with open surgery and by Mouiel et al. with
laparoscopic surgery, particularly when assessed by intra-operative
endoscopic Congo red test, is overall a very safe, patient compliant. It
has overall good recovery rates in terms of control of duodenal ulcer. It
is technically easy and can be do..c in a short time. It has a rrummum
post-operative morbidity and preserves near normal stomach when
compared with other procedures for duodena! ulcer.
After two years follow-up we had no recurrent cases and no cases
ofischemic necrosis oflesser curvature were encountered.
Also, we found that the intra-operative endoscopic Congo red test
was very beneficial in the intra-operative assessment, so we recommend
it as an essential step oflaparoscopic ASPTV.

1- A. Cuscbieri (1992):
-129-
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