Rehnberg O
Acta Chir Scand Suppl. 1983;515:1-63.
The results of a 5-year follow-up of 289 consecutive, peptic ulcer patients treated by antrectomy and gastroduodenostomy, with or without vagotomy, are presented. Patients with a preoperative gastric acid secretory capacity (PAO) below 40 mmol/h were treated by antrectomy alone, while subjects with a higher PAO had a vagotomy in addition. The antrectomy was defined by lithmus indication of the corpus-antrum border and by histologic verification, including gastrin cell counting. The over all incidence of gastroscopically verified recurrent ulceration was 8.5%. In patients with ulcer location in the bulb or the pyloric/prepyloric region (juxtapyloric ulcer) and treated by antrectomy alone, the recurrence rate was 18% (n = 102), and in gastric ulcer patients it was 4% (n = 47). Altogether 14 patients with recurrent ulcer were subsequently reoperated on by vagotomy showing no further recurrence. Antrectomy combined with vagotomy was primarily performed almost exclusively in patients with juxtapyloric ulceration, in whom the recurrence rate was 2% (n = 106). According to a postoperative insulin test, the patients with recurrence after antrectomy and vagotomy were incompletely vagotomized. In patients who remained free of symptoms or signs of recurrent disease, the median reduction in gastric acid secretory capacity was about 60% after antrectomy alone and 80% after antrectomy and vagotomy. In juxtapyloric ulcer patients with recurrence after antrectomy alone there was a small median reduction in PAO one month after operation (26%) and then an increase close to the preoperative level (6% reduction). In patients with a postoperative reduction in PAO of less than 35%, there was a high probability of recurrent ulcer, about 70%. In spite of selection of patients with a comparatively low preoperative PAO (less than 40 mmol/h) for antrectomy alone, the recurrence rate was 18% in patients with juxtapyloric ulcer location. In this selected group of patients the preoperative PAO was not higher in patients with ulcer recurrence than in patients who were asymptomatic after the operation. Selecting patients with juxtapyloric ulcer for antrectomy, with or without vagotomy, on the basis of gastric acid secretory capacity therefore seems unjustified. When vagotomy was added to antrectomy and gastroduodenostomy it seemed to increase the risk of developing serious (Visick 3u and 4) postgastrectomy syndromes; 12% after antrectomy and vagotomy versus 3% after antrectomy alone. Vagotomy appeared to be associated with an increased risk of bile reflux gastritis, gastric mycosis, and milk intolerance. Dumping and diarrhoea after vagotomy often coincided with milk intolerance. Antrectomy, with or without vagotomy, did not markedly impair recorded nutritional parameters.(ABSTRACT TRUNCATED AT 400 WORDS)
本文报告了289例连续性消化性溃疡患者接受胃窦切除术和胃十二指肠吻合术治疗（伴或不伴迷走神经切断术）的5年随访结果。术前胃酸分泌能力（PAO）低于40 mmol/h的患者仅接受胃窦切除术，而PAO较高的患者则加做迷走神经切断术。胃窦切除术通过石蕊指示胃体 - 胃窦边界并经组织学验证，包括胃泌素细胞计数来定义。经胃镜证实的复发性溃疡的总体发生率为8.5%。溃疡位于球部或幽门/幽门前区域（近幽门溃疡）且仅接受胃窦切除术治疗的患者，复发率为18%（n = 102），胃溃疡患者的复发率为4%（n = 47）。共有14例复发性溃疡患者随后接受了迷走神经切断术再次手术，未再复发。胃窦切除术联合迷走神经切断术主要几乎仅在近幽门溃疡患者中进行，其复发率为2%（n = 106）。根据术后胰岛素试验，胃窦切除术和迷走神经切断术后复发的患者迷走神经切断不完全。在未出现复发性疾病症状或体征的患者中，单纯胃窦切除术后胃酸分泌能力的中位数降低约60%，胃窦切除术和迷走神经切断术后降低80%。仅接受胃窦切除术的近幽门溃疡复发患者术后1个月PAO中位数有小幅降低（26%），然后接近术前水平升高（降低6%）。术后PAO降低小于35%的患者，复发性溃疡的可能性很高，约为70%。尽管选择术前PAO相对较低（小于40 mmol/h）的患者进行单纯胃窦切除术，但近幽门溃疡部位患者的复发率仍为18%。在这一选定的患者组中，溃疡复发患者的术前PAO并不高于术后无症状患者。因此，根据胃酸分泌能力选择近幽门溃疡患者进行胃窦切除术（伴或不伴迷走神经切断术）似乎不合理。当迷走神经切断术加至胃窦切除术和胃十二指肠吻合术时，似乎增加了发生严重（Visick 3级和4级）胃切除术后综合征的风险；胃窦切除术和迷走神经切断术后为12%，而单纯胃窦切除术后为3%。迷走神经切断术似乎与胆汁反流性胃炎、胃霉菌感染和牛奶不耐受风险增加有关。迷走神经切断术后的倾倒综合征和腹泻常与牛奶不耐受同时出现。胃窦切除术（伴或不伴迷走神经切断术）并未明显损害所记录的营养参数。（摘要截取自400字）
