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The earliest recorded operations on the stomach were performed for penetrating injuries.1 In the late 1800s, experimental studies in the surgical laboratories of Billroth confirmed the feasibility of removing the pylorus, a concept developed by Michaelis in the early part of that century. In 1881, Rydygier performed the first successful pylorectomy, and in 1884 he performed the first gastroenterostomy. Both of these operations were performed for complications of benign peptic ulcer disease. In 1881, Billroth performed the first successful pylorectomy for malignancy. In this case, the duodenum was anastomosed to the lesser curvature of the stomach and the greater curvature was oversewn. The patient initially did well but died from disseminated abdominal carcinomatosis 4 months later. In 1885, Billroth performed a resection of a large pyloric carcinoma, using an anterior gastrojejunostomy for the reconstruction. In subsequent years, Billroth, his students, and others devised several approaches to gastroduodenal and gastrojejunal reconstruction.1–3 Following popularization of gastrojejunostomy for reconstruction after gastric resection or palliation of unresectable gastric malignancy, surgeons were confronted with early complications such as bleeding, anastomotic leak, intestinal obstruction, and late complications such as stomal ulceration, bilious vomiting, afferent and efferent limb obstructions, and dumping.4,5 At present, these problems remain only partially understood and controllable.


Pyloroplasty was initially devised by Heineke for treatment of congenital hypertrophic pyloric stenosis, and the results were poor. Jaboulay's side-to-side anastomosis of the distal greater curvature and duodenum in 1892, and the Faience extension of this anastomosis to include the pylorus itself were subsequently refined by Kocher. Kocher improved the technical ease of the operation by including a mobilization of the duodenum from its lateral peritoneal attachments. The first pyloromyotomy was performed for this lesion in 1912 by Ramstedt.


In the early part of the 20th century, a dramatic rise was observed in the incidence of duodenal ulceration. A period of intense clinical and laboratory investigation from 1920 through 1940 led to the recognition that surgically performed vagotomy could reduce gastric acidity under resting conditions and in response to luminal and humoral stimuli. The use of vagotomy for patients with complications of ulcer disease was pioneered by Latarjet, who reported 24 such cases in 1922. Latarjet himself recognized that vagotomy might lead to delayed gastric emptying and had added a drainage procedure, gastrojejunostomy. Confusion regarding the role of delayed gastric emptying in the pathogenesis of peptic ulcers, however, led many surgeons away from vagotomy and drainage as a treatment for recurrent peptic ulceration. It remained for Dragstedt and his colleagues at the University of Chicago to resurrect this concept in the 1940s.5 Subsequently, Farmer, Smithwick, and others introduced the combination of truncal vagotomy (TV) and hemigastrectomy, an operation that also removed the gastrin-producing antral mucosa.3 In the 1950s, Harkins' group in Seattle began to evaluate forms of vagotomy that left intact the celiac and hepatic branches (proximal selective vagotomy), along with or in combination with the preservation of vagal motor branches ...

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