Acta chir belg, 2005, 105, 121-126 Introduction One hundred years ago Pavlov delivered his lecture as laureate for the Nobel Prize in Physiology and Medicine. He showed that the nervous system played a dominant role in the regulation of digestive processes. He stated : “So the stimulation effected by the act of eat- ing reaches the gastric glands by means of the nerve fibers that are contained in the vagus nerves” (1). This was the advent of modern physiology of digestion and has added to the paradigm “no acid – no ulcer”. Its prin- ciples also served as a basis for vagotomy as surgical treatment of peptic ulcer disease. A parallelism between the surgical and pharmacological acid reducing approach could be observed. With the discovery of the role of Helicobacter pylori in peptic ulcer disease, the importance of a shift in paradigm on the therapeutic approach of peptic ulcer disease is highlighted. The causal model of peptic ulcer It was stated that, without active gastric secretion, no peptic ulcer would occur. An imbalance between the defense – the gastric mucosa – and the aggression – the gastric acid – was proposed as a mechanism. An overview of available treatments for peptic ulcer in 1960 showed that most researchers focused their attention on the defensive mechanisms (2). The mechanisms held responsible for the formation of peptic ulcers were a) spasms of small arteries in the gastric wall with decreased mucosal defense, b) increased gastric acid production in patients with a duodenal ulcer, c) increased stress after trauma or major surgery, d) neu- rological stimuli causing pyloric spasms and retention of gastric acid and e) infections. The latter, with primary foci in the dental region and haematogenic dissemina- tion to the gastic mucosa was already proposed in 1916, after elaborate experiments with streptococci (3). The role of gastroduodenal mucosal inflammation in relation to infection as a precondition for ulceration was investi- gated as early as 1923 (4). The production of gastric acid played the most important role in the causal model of this disease. This thinking had a profound influence on the medical and surgical approach. In both fields, research was stimulated towards reduction of gastric acid secretion with emphasis on the reduction of the side effects of the existing treatments. Development of highly selective (or parietal cell or proximal gastric) vagotomy Despite the statement of Pavlov, surgical treatment of peptic ulcer disease in the first decades of the twentieth century was mainly gastro-enterostomy. Ulcer recur- rence after this procedure, however, was unacceptably high. Gastric resection was another operative treatment Current Status of Proximal Gastric Vagotomy, One Hundred Years after Pavlov : is it Finally History ? W. Mistiaen*, R. Van Hee**, H. Bortier* Laboratory for Human Anatomy and Embryology*, University of Antwerp, Belgium ; Dept of Surgery**, General hospital Stuivenberg, Antwerp, Belgium. Key words. Gastric ulcer ; gastric acid ; Helicobacter pylori ; vagotomy ; antibiotics ; resistance. Abstract. One hundred years ago, the role of the vagal nerve in gastric acid production was established. After the sec- ond World War, this paradigm served as the basis of treatment of peptic ulcer disease by pharmacological or surgical means. A remarkable parallelism between the developments of both approaches was observed in the 1970s. On the one hand, medication with less side effects became available. On the other hand, vagotomies were becoming more physio- logic in nature and produced less postoperative symptoms. The elusive nature of peptic ulcer disease and the inability to cure this by medication were acknowledged. Very few investigators, however, had reported on a possible infectious origin of peptic ulcer disease and those reports were old. After 1984, the role of Helicobacter pylori in the disease was discovered. With this shift in paradigm, the treatment of peptic ulcer disease changed radically, despite attempts in the surgical community to develop simplified operations. This illustrates that neither the most powerful acid reducing drugs on their own, nor the most physiological and least invasive surgical techniques stand the test of time if the underlying paradigm changes. It also illustrates that old ideas should not be overlooked. Review papers