A 50-year perspective upon selective gastric vagotomy

The occurrence of postvagotomy complications was initially considered an unavoidable but acceptable consequence of duodenal ulcer surgery. Following the description of “selective” vagotomy procedures, however, it became apparent that effective ulcer surgery might be accomplished without unpleasant sequellae. In 1957 the experimental basis for “highly” selective vagotomy (HSV), which preserved antral innervation, was reported. HSV was performed in several European centers between 1960 and 1968, and was widely accepted there. Surgeons in the United States, in contrast, were largely reluctant to use HSV, an operation which had an excessive ulcer recurrence rate compared to vagotomy-antrectomy. More recently, HSV is recognized as a successful operation, due to more complete division of preganglionic gastric vagal nerves (“extended” HSV) and the liberal use of pyloric reconstruction in patients with juxtapyloric ulcers. HSV is performed with minimal morbidity, with an incidence of recurrent ulcer which is less than 5%. Complications such as dumping, diarrhea, and gastric atony are quite rare. HSV is an ideal procedure for most patients with duodenal ulcer. Because most operations for ulcer are performed for urgent or lifethreatening problems, the most common operation performed in the United States today is truncal vagotomy combined with pyloroplasty or gastric resection. Earlier operation for chronic ulcer has many potential advantages.