Selective and Total Vagotomy Plus Pyloroplasty:
A Comparative Study of Gastric Secretion and
Motility in Dogs
M. T. EvEshT,* M.B., B.S., F.R.C.S., CHARmL A. GRmm,** M.D., M.Sc., F.A.C.S.
From the Department of Surgery, University of Washington School of Medicine,
Seattle, Washington 98105
IN a previous study of Heidenhain pouch
dogs it was found that pouch secretion
after total vagotomy without drainage was
almost twice as great as after selective va-
gotomy without drainage.18 The mecha-
nism for this difference in pouch secretion
was unexplained, and it was postulated
that the hepatic and celiac vagi in some
way inhibit gastric secretion. Evidence in
support of this postulate is the recent find-
ing that insulin inhibits the feeding re-
sponse of Heidenhain pouches in dogs with
selective vagotomy.1 The present study was
undertaken to determine the additional ef-
fect of pyloroplasty and its possible clini-
cal significance.
Material and Methods
Four adult mongrel dogs weighing be-
tween 11 and 18 Kilos underwent three
staged procedures: Stage I, Heidenhain
pouch; Stage II, selective gastric vagotomy;
and Stage III, total abdominal vagotomy.
Submitted for publication April 7, 1969.
* Visiting Scientist from United Cardiff Hos-
pitals and in receipt of a Wellcome Research
Travel Grant.
** Clinical Associate Professor of Surgery.
This study was aided by funds accruing from
National Institutes of Health Grant AM08094.
31
A Finney pyloroplasty was constructed at
Stage I in dogs ME13 and ME19, and at
Stage II in dogs ME2 and ME3. The op-
erative technics and methods were the
same as described in the previous study'8
without pyloroplasty.
Selective vagotomy was performed at the
gastric cardia with transection of the gas-
tric vagi and preservation of the hepatic
and celiac vagi. Total vagotomy was per-
formed by transecting the hepatic and
celiac vagi; the vagal trunks were not dis-
turbed so that a possibly incomplete gas-
tric vagotomy by the initial selective tech-
nic was not converted into a complete gas-
tric vagotomy by the truncal technic.
A minimum of thirty 24-hour Heiden-
hain pouch secretions were obtained after
each stage. Collections were not started
until the pouch secretions had stabilized
approximately 4 weeks after operation. Re-
sults were expressed as mEq. of total (pH
7) titratable acid.
Two insulin tests were performed on
each animal after selective vagotomy, but
absolute reliance could not be placed on
these tests owing to the occasional occur-
rence of neutralizing duodenal regurgita-
tion. Accordingly, as an additional test
after total vagotomy, the vagal trunks were
stimulated electrically in the presence of
32 EVERETT AND GRIFFITH Annals of Surgery
January 1970
TABLE 1. Results of Completeness of Vagotomy

Residually
Insulin Tests Innervated Mucosa
Dog Hollander's Stempien's Secreting Neutral
No. Criteria Criteria Red

1st test neg neg

ME2 2nd test neg neg 2.2%
1st test neg neg
ME3 2nd test neg neg 12.0%
1st test neg pos
ME13 2nd test neg pos 1.4%
1st test neg neg
ME19 2nd test neg neg None

The positive insulin tests in dog ME13 were small and delayed responses indicative of small areas of residual
innervation and adequate vagotomy.
The residually innervated mucosa in dogs ME2, ME3 and ME13 that secreted neutral red were in the proximal
fundus. The percentage figures relate the size of the area of residually innervated mucosa to the entire mucosal
surface.

circulating neutral red to demonstrate any Results

residual gastric innervation.15 Lastly, the
abdominal vagi were dissected at post-
mortem examination.
Gastric emptying time and small intes-
tinal transit time (time for head of meal
to pass from pylorus to cecum) were re-
corded at each stage of the study. Control
films were taken at the end of the control
pouch collection period (2 months postop-
erative Stage I), and films taken at both
start and finish of the subsequent collec-
tion periods (one and two months postop-
erative Stages II and III). Following 24
hours starvation, during which water was
allowed, dogs ME2 and 3 were fed a well
mixed meal of 105 Gm. Gerber's beef liver
and 80 Gm. barium sulphate. The two
other smaller dogs had exactly half; 52.5
Gm. and 40 Gm. The resultant mixture
was semisolid. Each individual animal was
given the same size meal throughout the
study. Films were taken at 15 min. inter-
vals after the feed until radio-opaque ma-
terial was seen to start leaving the stomach.
Thereafter, films were taken at 1/2 hourly
intervals.
All four dogs remained in good health
throughout the period of study, and weight
loss was minimal.
Results of the tests for completeness of
gastric vagotomy are presented in Table 1.
The insulin tests after selective vagotomy
were negative in all dogs by Hollander's
criteria,7 and in three of the four dogs
negative also to Stempien's criteria.21 The
response in the four dog (ME13) was of
the small and delayed type. In this animal,
and in two others, a small fundic area of
residual gastric innervation was demon-
strated by the method of neutral red. The
site of these areas, and their small size ex-
pressed as a percentage of whole stomach
area by the method of pattern-weight 14
denote the presence of an intact fundic
branch with complete gastric denervation
of the antrum and remaining corpus.'5
Postmortem dissections confirmed the sec-
tion of the major anterior and posterior
gastric divisions in all dogs, and demon-
strated an intact posterior fundic branch
in dogs ME2 and 3; in dog ME13 postop-
erative adhesions thwarted identification of
Volume 171 SELECTIVE AND TOTAL VAGOTOMY PLUS PYLOROPLASTY
Number 1 33
H.P control Selective gastric
vagotomy Total vagotomy
i- 7- Finney pyloropi.
6-
FIG. 1. Gastric empty- 5-
ing times (top) and small .0Z
, 4-
intestinal transit times
(bottom) after each op- 3-
erative stage. Left: Dogs
ME2 and ME3 with .t1
-
I
Heidenhain pouch at * ME 2 - - I
Stage I. Right: Dogs o ME3
ME13 and ME19 with
Heidenhain pouch plus A
Finney pyloroplasty at .k0~Iz
Stage I. 7 4 _
, 2
I
Monthpost.op.2 1 2 1 2
4 Mean of Mean of Mean of Mean of 1
value
2 values 2values 2values 2volues

an intact fundic branch. The anterior and and MEl9 (p < 0.001) and a questionably
posterior vagal trunks and the origins of significant decrease in dog ME2 (p <
their hepatic and celiac divisions were in- 0.05). The grouped data show that secre-
tact in all dogs, which finding indicates tion after total vagotomy is almost twice as
their preservation at the stage of selective great as after selective vagotomy (Fig. 2).
vagotomy. The peripheral hepatic and
celiac vagi were completely transected in Discussion
all dogs, thus confirming that complete he- As in the previous study without drain-
patic plus complete celiac vagotomy was age, Heidenhain pouch secretion in the
successfully accomplished at the subse- present study with pyloroplasty was sig-
quent stage of total vagotomy. nificantly greater after total vagotomy than
Gastric emptying time was reduced after
selective vagotomy plus pyloroplasty in
dogs ME2 and ME3. In dogs ME13 and Control Selective Total
MEl9 the addition of selective vagotomy 47.2 Vagotomy Vagotomy
to pyloroplasty did not result in gastric
stasis. The addition of total vagotomy did 000.0
0.000
00 00

not alter the rate of gastric emptying or 000.0

intestinal transit time in any dog (Fig. 1). 000
* 0tSE0
No intestinal dilatation was seen. At post- .....
mortem examinations all pyloroplasties
00 00

were adequate and patent.

00
@00060
00
21.8
00.00
00
0z
*000060
00

S....
.....
The changes in Heidenhain pouch secre- *
00

5z
5000
00

tions (Table 2) after selective vagotomy .....

* 0*
were a significant decrease in dogs ME3
and ME13 (p < 0.001) a questionably sig-
nificant decrease in dog ME2 (p < 0.05),
and an insignificant increase in dog ME19. mEq
The changes after total vagotomy were a FiG. 2. Grouped data of Heidenhain pouch se-
cretion (mean mEq. of 30 day collections) after
significant increase in dogs ME3, ME13, each operative stage.
34
TABLE 2. 30-day Means of Heidenhain Pouch Acid
Output in Total mEq.
Stage I Stage II
Dog ME2 22.2 4- 7.8 17.5 4 4.5
Dog ME3 68.7 i 20.2 26.5 :1 10.8
Dog ME13 78.1 i 17.0 31.6 A 6.4
Dog ME19 9.95 4 2.0 11.7 4 5.5
after selective vagotomy. This difference
occurred in three of the four dogs studied.
Why the fourth dog (ME2) did not show
this difference is unknown.
Although the mechanism for different
pouch secretions after selective and total
vagotomy is also unknown, the results of
this study indicate that gastric stasis is not
a factor. Furthermore, as in previous study,
the difference occurs when the gastric va-
gotomy is complete or virtually complete
with only a small percentage of residual
fundic innervation. This type of incom-
plete vagotomy reduces gastric acid secre-
tion almost as much as complete vagot-
omy."1 Therefore, the difference in pouch
secretion cannot be explained by differ-
ences in completeness of vagotomy or gas-
tric secretion.
There is unquestioned evidence that an
intestinal mechanism exists. Kelly et al.8
demonstrated an enhanced Heidenhain
pouch output after hepatic and celiac va-
gotomy in the total absence of the stomach
(bar the pouch); Middleton et al.12 con-
firmed this finding, and added the primary
importance of the celiac division. Landor'0
also showed that hepatic and celiac va-
gotomy augmented Heidenhain pouch dogs
with antrectomy. Of the four known mecha-
nisms that could explain this augmentation,
none seem to be responsible. Duodenal
acid inhibition was nonoperative in the
preparation used by Kelly et al. and Mid-
dleton et al. above. Halvorsen et al.6 using
a similar total gastrectomy preparation to
study enterogastrone release, found no dif-
ference in the effect of duodenal fat upon
EVERETT AND GRIFFITH Annals of Surgery
January 1970
Heidenhain pouch secretion before and
after hepatic and celiac vagotomy. The
Stage III serotonin mediated inhibitory mechanism
by acid in the jejunum, recently reported
14.7 4 4.8 by Schuck et al.,18 was shown by these au-
41.2 4 17.0 thors to be unchanged by total vagotomy;
66.5 4 18.4
33.5 4 10.9 the effect of hepatic and celiac section
alone, however, was not determined. The
fourth possible mode of action, an en-
hanced release or action of intestinal gas-
trin by intestinal distention,'3 19 would
seem to be excluded by the finding that
neither intestinal stasis nor distention oc-
curred after hepatic and celiac vagotomy
in this study. If, as we postulate that the
hepatic and celiac vagi inhibit gastric se-
cretion, it is clear from all evidence to date
that the inhibition is at least partially
mediated through the mid gut. Whether
the antrum also participates is unknown.
The results of this and all other studies
imply that selective vagotomy lowers gas-
tric secretion more effectively than total
vagotomy, and therefore may provide bet-
ter protection against recurrent ulcer. This
suggestion is neither proven nor disproven
by the available clinical evidence. On the
one hand, Bank et al.2 concluded from
their results with insulin and histamine
tests that the reduction in gastric acidity
by selective and total vagotomy in man is
the same. In support of their conclusion
are the results of Kraft et al.9 and Smith
and Farris,20 who reported comparable
rates of recurrent ulcer after selective and
total vagotomy. On the other hand, the re-
ports of Herrington," Burge,3 Scott17 and
Griffith4 suggest that, in patients with com-
plete or adequate vagotomy plus adequate
drainage by pyloroplasty, recurrent ulcer
after selective vagotomy is less than after
total vagotomy. Further experimental and
clinical investigation seems warranted.
Summary and Conclusions
The effects of selective and total va-
gotomy plus pyloroplasty upon gastric se-
Volume 171 SELECTIVE AND TOTAL VAGOTOMY PLUS PYLOROPLASTY
Number 1
cretion and gastrointestinal motility were
compared in four Heidenhain pouch dogs.
Whereas there was no difference in gastro-
intestinal motility, the grouped data of
pouch secretion was almost twice as great
after total vagotomy as after selective va-
gotomy. The explanation for this difference
in pouch secretion is unknown, and it is
postulated that the hepatic and celiac vagi
inhibit gastric secretion. If applicable to
man, selective vagotomy may lower gas-
tric secretion more effectively and provide
better protection against recurrent ulcer
than total vagotomy.
References
1. Amdrup, B. M. and Griffith, C. A.: The Ef-
fects of Insulin and Hexamethonium upon
the Feeding Response of Heidenhain Pouches
in Dogs with Selective Vagotomy of the Pa-
rietal Cell Mass. Submitted for Publication
to Scand. J. Gastroenterology.
2. Bank, S., Marks, I. N. and Louw, J. H.: His-
tamine- and Insulin-Stimulated Gastric Acid
Secretion after Selective and Truncal Va-
gotomy. Gut, 8:36, 1967.
3. Burge, H.: Personal Communication, 1968.
4. Griffith, C. A.: Significant Functions of the
Hepatic and Celiac Vagi. Amer. J. Surg.,
118: (Aug.) 1969.
5. Halvarson, H. C., Middleton, M. D., Bibler,
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6. Herrington, J. L., Jr.: Vagotomy-Pyloroplasty
for Duodenal Ulcer: A Critical Appraisal of
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8. Kelly, K. A., Nyhus, L. M. and Harkins,
H. N.: The Vagal Nerve and the Intestinal
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