Charles A. Griffith

Gallstones after vagotomy

A control group of 53 patients with selective vagotomy plus pyloroplasty was studied with pre- and postoperative cholecystography. At the fourth to seventh years the size and motility of the gallbladders were the same. Gallstones developed in two patients. A series of 91 patients with total vagotomy plus pyloroplasty was studied by similar methods. In 46 patients the gallbladders were grossly dilated and in 30 of the 46 the gallbladders were noncontractile. Gallstones developed in nine of the 46 patients. In the other 45 patients hypotonic dysfunction of the gallbladder was insignificant, and stones developed in only 1 of them. Explanation of these variable results is thwarted by unknown variations in the degree of both hypotonic dysfunction of the gallbladder and lithogenic change in the bile of patients with complete hepatic and complete celiac vagotomy after total vagotomy, and also by the unknown occurrence of incomplete hepatic and incomplete celiac vagotomy in series of allegedly complete total vagotomy. It is concluded that total vagotomy increases the incidence of gallstones, and that this increase occurs primarily in patients with significant hypotonia of the gallbladder. Selective vagotomy prevents these sequelae.

The abdominal vagal system in rats. An anatomical study with emphasis upon the distribution of the gastric vagi to the stomach.

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

A physiologic study of motility changes following selective gastric vagotomy

Summary Physiologic studies were done in dogs with stimulation of the thoracic vagus and recording of motility changes in the abdominal viscera, namely the stomach, first part of the duodenum, third part of the duodenum, jejunum, ileum, colon and gallbladder. We have shown by this technique that: o 1. Following selective gastric vagotomy, the motility response in the stomach is totally absent while the remaining viscera are reactive. 2. The influence of the gastric branches from either right or left trunk extends through the second part of the duodenum. 3. The hepatic branch of the left vagus innervates the gallbladder and proximal duodenum but has no influence on the stomach. 4. The celiac branch influences the entire gastrointestinal tract from the proximal duodenum through the ascending colon. 5. Selective gastric vagotomy may prove to be a logical refinement of total abdominal vagotomy.

Significant functions of the hepatic and celiac vagi

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

The Marcy Repair Revisited

Failure to close the internal ring in transversalis fascia is the primary cause of recurrent indirect inguinal hernia. Removal of the cremaster muscle provides optimal exposure for accurate identification and fascial closure of the ring.

The Marcy Repair of Indirect Inguinal Hernia

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

Completeness of gastric vagotomy by the selective technic

In answer to the questions posed at the beginning of this report, the following conclusions were reached: 1. With the unproven but possible exception of residual antral innervation in some but not all patients, preservation of the hepatic and celiac vagi by the selective technic permits complete vagotomy of the stomach in man. 2. The selective technic provides consistently successful results of permanently complete or adequate vagotomy and climinates the occurrence of inadequate vagotomy. 3. These results are based on the anatomic accuracy of the selective technic in providing the means for the positive encirclement and transection of all gastric vagi. With the unproven but possible exception of residual antral innervation in some but not all patients, preservation of the hepatic and celiac vagi by the selective technic permits complete vagotomy of the stomach in man. The selective technic provides consistently successful results of permanently complete or adequate vagotomy and climinates the occurrence of inadequate vagotomy. These results are based on the anatomic accuracy of the selective technic in providing the means for the positive encirclement and transection of all gastric vagi.ConclusionsIn answer to the questions posed at the beginning of this report, the following conclusions were reached:1.With the unproven but possible exception of residual antral innervation in some but not all patients, preservation of the hepatic and celiac vagi by the selective technic permits complete vagotomy of the stomach in man.2.The selective technic provides consistently successful results of permanently complete or adequate vagotomy and climinates the occurrence of inadequate vagotomy.3.These results are based on the anatomic accuracy of the selective technic in providing the means for the positive encirclement and transection of all gastric vagi.

The effects of vagotomy upon biliary function in dogs

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

Long-term results of selective vagotomy plus pyloroplasty: 12 to 17 year follow-up☆

Among an initial series of 103 patients with selective vagotomy plus pyloroplasty for duodenal ulcer, 9 patients died of causes unrelated to ulcer and 7 were lost to follow-up without signs or symptoms of ulcer 8 to 15 years after operation; the remaining 87 patients were followed up for 12 to 17 years. Insulin testing revealed only one inadequate vagotomy in a patient who had a recurrence in the short term. Insulin tests were negative in 61 and negative or adequate in 6 other patients. Complete vagotomy reduced basal secretion effectively in the great majority of patients but not in a small minority. Three patients had antral hyperfunction with persistent hypersecretion despite complete vagotomy as indicated by two negative insulin tests in each patient. Inexplicably, only one of these patients had a stomal ulcer recurrence. Long-term follow-up revealed the development of gastric ulcer in one patient wit stasis from a pyloroplasty stenosed by angulation from adhesions. Three other patients, one with ulcer and two with hemorrhagic gastritis, developed gastric ulceration in the long term despite low acid output and negative insulin tests. Biliary reflux was demonstrated in two of these three patients and was probably the cause of gastric ulcer in the third. Pre- and postoperative cholecystograms in 66 patients showed the formation of gallstones in 4 patients after vagotomy. Another patient who did not undergo cholecystography developed acute cholecystitis from stone. This rate of gallstone formation was the normal expected rate and was not increased as in some series of total vagotomy. Dumping with and without associated diarrhea was the most frequent and troublesome sequela. Postvagotomy diarrhea did not occur. To prevent dumping, and also to decrease acid secretion more effectively, pyloroplasty was abandoned in favor of Makis pyloruspreserving antrectomy to complement selective vagotomy in 1968.

Selective gastric vagotomy combined with hemigastrectomy and Billroth I anastomosis

Abstract Our current operation of choice for duodenal ulcer is (1) selective gastric vagotomy, (2) hemigastrectomy and (3) gastroduodenostomy. Each of these three steps has been investigated in our laboratory prior to clinical application. From this experience we believe that each has its own merits, and that each supplements the other. In regard to the factors of (1) recurrent ulcer, (2) gastrointestinal dysfunction and (3) operative morbidity and mortality, we evaluate the procedure as follows: Recurrent Ulcer. Selective gastric vagotomy provides a method for the consistent performance of complete and total gastric vagotomy. Hemigastrectomy as described herein provides a method for the consistent performance of complete excision of the antrum. By the consistent and accurate elimination of both the cephalic and antral phases of gastric secretion, selective gastric vagotomy plus hemigastrectomy provides more consistent protection against recurrent ulcer than any other conventional procedure. Gastrointestinal Dysfunction. By confining vagal denervation to the stomach, selective gastric vagotomy does not interfere with vagal innervation of other abdominal viscera. Undesirable sequelae of vagotomy of the biliary tract, pancreas and bowel are, therefore, eliminated. By preserving approximately half the stomach, hemigastrectomy does not jeopardize the function of the stomach as a reservoir. Undesirable sequelae of a small gastric remnant are, therefore, eliminated. By maintaining gastroduodenal continuity, gastroduodenostomy preserves the normal physiologic sequence of the gastrointestinal tract for optimal digestion and absorption. Nutrition and weight are regularly maintained after selective gastric vagotomy, hemigastrectomy and gastroduodenostomy. Careful follow-up examination indicates that dumping is the only disturbance. However, the incidence and severity of dumping are considerably less than in subtotal gastric resection and comparable to vagotomy plus pyloroplasty. Operative Morbidity and Mortality. The magnitude of the operation, in terms of time and extent of dissection, contraindicates the performance of selective gastric vagotomy, hemigastrectomy and gastroduodenostomy in all patients. We perform and recommend less extensive and less time-consuming operations for patients considered poor surgical risks. However, for the usual elective patient considered a good surgical risk, our experience indicates that selective gastric vagotomy, hemigastrectomy and gastroduodenostomy have not increased our operative morbidity and mortality. We, therefore, choose to perform this procedure upon patients considered good surgical risks to gain the advantages of maximal protection against recurrent ulcer with a minimal disturbance of gastrointestinal function.