Posterior vagotomy and anterior seromyotomy as elective surgery for duodenal ulcer disease.

BACKGROUND/AIMS: The introduction of acid-reductor drugs in the treatment of duodenal ulcer has led to a drastic reduction in surgical indications. The role of Helicobacter pylori in recurrence and persistence of ulcer has added antibiotics to H2-receptor blockers and proton pump inhibitors. As this triple drug therapy always involves long and short-term side effects and ulcer recurrence is frequent once medication is stopped, surgical treatment with its recognized long-term efficacy has a role to play in prevention of complications. Posterior truncal vagotomy and anterior seromyotomy will guarantee complete denervation of the posterior territory and hence post-vagotomy diarrhea is avoided and motility is maintained in the pyloric and antral regions.

METHODOLOGY

Elective posterior vagotomy and anterior seromyotomy was performed on 75 patients (14 F, 61 M) aged 19-61 years with a duodenal ulcer refractory to medical treatment. Sixty-two of them were followed-up for at least 2 years. Vagotomy is performed with the patient in the same position as for cholecystectomy. Five trocars are routinely inserted. The procedure involves three steps: approach for the hiatal region, posterior vagotomy, and anterior seromyotomy.

RESULTS

Mean operative time was 140 min (range: 120-220 min). There was no mortality and only one case of pneumothorax which was treated successfully by a chest drainage. As for long-term, one patient developed reflux esophagitis. Fifty-nine patients had healing of their ulcer and 3 other patients had presence of scars 2 months after the operation. Post-operative BAO decreased to 78% and pentagastrin-stimulated acid secretion to 80%. Two pre-pyloric ulcer recurrences occurred 2 years after surgery, which responded to medical therapy. At 2 years, a 65% reduction in both BAO and pentagastrin-stimulated acid secretion was recorded.

CONCLUSIONS

Posterior truncal vagotomy with anterior seromyotomy combines the rapidity and effectiveness of truncal vagotomy, which has the advantage of maintaining the gastric antral pump with ultra selective vagotomy. This minimally invasive surgical approach has opened up a new era in effective treatment of ulcer disease, and from now on must represent an alternative to long-term medical therapy.