Current Controversies in the Surgical Management of Peptic Ulcer Disease Arthur T. Davidson, MD Bronx New York
Surgical treatment of peptic ulcer disease is the treatment of its complications. These complications - the same for all parts of the GI tract - are (1) intractability, (2) hemorrhage, (3) obstruction, (4) perforation, and (5) malignancy. During the past 25 years there have been major changes in the types of surgical approaches to each of the complications. Indeed, in November 1976, the University of Colorado School of Medicine presented a postgraduate course entitled Gastric Surgery: The Quiet Revolution.1 As with any revolution, albeit quiet, the basic thrust was the controversy over how best to deal with the problems at hand. Some of these controversies which are of current interest will be addressed.
Definitions The indications for operations in each of the complications presented are: 1. Intractability (50-5 5 percent of patients operated on)2
Read at the Sixth Annual Convention and Scientific Assembly of Region of the National Medical Association, Kiamesha Lake, New York, May 27-30, 1977. Requests for reprints should be addressed to Dr. Arthur T. Davidson, 1378 President Street, New York, NY 11213.
900
a. Ulcer must be confirmed - endoscopy if necessary b. Symptoms inhibit productive life c. Patient cannot/will not follow medical treatment d. Location of ulcer: Postbulbar or pyloric channel 2. Hemorrhage (20-25 percent of patients operated on)3 a. Massive bleeding after age 60 years b. Massive bleeding and previous major complication c. Repeated non-massive bleeding: Over age 60 years; Previous major complication; Patient will not/cannot follow treatment. 3. Obstruction (1-15 percent of patients operated on) a. No relief with 72 hours of nasogastric suction b. Previous major complication 4. Perforation (5-10 percent of patients operated on)4 a. Surgery, the treatment of choice 5. Malignancy (Almost 100 percent gastric in location and associated with absence of free acid) a. Surgery, the only treatment
Physiology Basic to the understanding of the pathogenesis of peptic ulceration is awareness of the production of acid by the stomach. It is interesting to note that other than the human stomach, the only organisms capable of producing a strong acid are certain mol-
luscs that produce sulphuric acid for defense purposes. These unicellular organisms elaborate a fluid with a low pH (as low as 1.0) in their vacuoles. The human stomach has scattered throughout its mucosa innumerable small tubular units which constitute the gastric glands. The glands anatomically consist of a narrow short superficial part, the neck, and a thicker longer portion, the body, which almost reaches to the muscularis mucosae. The blind extremity of these glands may be club shaped, indented, or branched. It has been estimated that these glands total about 35 million. The cellular structure of the glands is of great interest. The walls are composed of three types of cells: (1) chief cells of the neck or mucous neck cells, (2) chief cells of the body or zymogenic cells, and (3) parietal or border cells. The mucous cells secrete mucous only. The zymogenic cells secrete pepsin, a gastric enzyme that degrades proteins to peptones. It only acts in an acid medium. The parietal cells secrete hydrochloric acid. A very important anatomical point is that the gastric glands in the region of pylorus and those near the cardiac orifice contain only mucous cells and thus are capable of secreting only a mucus. The parietal cells are found only in those gastric glands located in the body and fundus. The hormone gastrin is produced by the glands in the pylorus or antrum of the stomach. The action of this hormone is one of the
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 12, 1977
two mechanisms responsible for the secretion of hydrochloric acid by the parietal cells in the fundus and body. The other mechanism is by vagal stimulation of the fundus and body of the stomach. Thus, one can see that the prevention of the secretion of hydrochloric acid lies in: (1) prevention of vagal stimulation and/or (2) removal of gastrin stimulation.5
Therapy for Complications In the treatment of peptic ulcer we must first differentiate between gastric and duodenal ulcers. Treatment of gastric ulcer - a totally different disease - offers no controversy as to the surgical treatment. If a diagnosis of chronic gastric ulcer is made, then all authorities agree that resection probably hemigastrectomy and vagotomy - is the treatment of choice. Past and current controversy continue debating the best surgical operation for the treatment of duodenal ulcer. Since duodenal ulcer results from a high concentration of gastric hydrochloric acid, the options for surgery are thus made more complex.6 Intractability The first operation used in the treatment of duodenal ulcer was the gastroenterostomy. This operation was very effective but was followed by the recurrence of the ulcer in approximately 30 percent of cases, when followed for long periods (up to 23 years). Noting the high incidence of recurrence, surgeons instituted a more radical operation, ie, a 60 to 80 percent distal subtotal gastrectomy. This proved effective because it removed (1) the antral gastrin mechanism and (2) a large part of the acid-producing parietal cell mass. Its drawbacks were that it caused a significant number of complications and mortalities. Dragstedt made a significant contribution to duodenal ulcer surgery by initiating the use of sectioning of the vagus nerves in order to decrease the stimulation of acid secretion.6 As a physiologist, he was aware of the significant role that (1) the vagi played in the stimulation of the secretion of acid by the parietal cells and (2) of the invariable association of the hypersecretion of acid with a duodenal ulcer. After noticing that his early cases had great difficulty with gastric emptying, he added gastroenterostomy to bilateral vagus section.
Since 1960, truncal vagotomy with either gastroenterostomy or pyloroplasty has achieved wide useage in England and the United States.7-10 It may well be that it is now the surgical procedure of choice for the treatment of duodenal ulcer. Its significant advantage is its low mortality rate but it has a significant incidence of ulcer recurrence - in the neighborhood of eight to ten percent. In an effort to combine the best of both worlds, surgeons began to combine vagotomy and antrectomy. It has a low recurrence rate, probably less than one percent, but it is associated with a rather high mortality rate (1.5 to 2 percent). One of the current controversies in the surgical treatment of duodenal ulcer disease is whether to use vagotomy with a drainage procedure or vagotomy with antrectomy. When analyzing the effectiveness of vagotomy plus gastroenterostomy or antrectomy versus subtotal gastrectomy, one of the most comprehensive and detailed comparisons was presented by Goligher7 of England. He used as his evaluation yardstick the following classification: 1. Excellent - No symptoms 2. Very good - Occasional mild symptoms 3. Satisfactory - Moderate symptoms - some discomfort 4. Unsatisfactory - Moderate to severe symptoms which interfere considerably with work or enjoyment of life. Both patient and doctor dissatisfied with results. Includes all cases of proven recurrent ulcers. A three-year follow-up of approximately 634 cases revealed that subtotal gastrectomy had the least number of cases in category 4. However, when comparing the number of cases in categories 1 and 2, vagotomy and antrectomy gave slightly better results than subtotal gastrectomy (78 to 77 percent). Vagotomy and gastroenterostomy had 70 percent of its cases in categories 1 and 2. Subtotal gastrectomy had the lowest incidence (two to five percent) of recurrent ulceration over a period of five to eight years. The incidence of recurrence after vagotomy and gastroenterostomy was approximately seven to ten percent. And, after vagotomy and antrectomy, Goligher reported the rather high figures of two to six percent. This does not compare with most American series where the recur-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 12 1977
rence rate, following vagotomy and antrectomy, has the extraordinarily low recurrence rate of less than one
percent.7 Malabsorption and metabolic ill effects were greater following gastrectomy and vagotomy with antrectomy than with vagotomy with gastroenterostomy. Subtotal gastrectomy had the highest mortality rate (one to two percent) followed by vagotomy and antrectomy. Vagotomy with gastroenterostomy had the lowest mortality rate (less than 0.5 percent).7 In a later series, Goligher compared the results of vagotomy with pyloroplasty with the three procedures. He found that recurrent ulceration was much higher after vagotomy with pyloroplasty than with the other three
procedures.8 Kennedy of England compared vagotomy plus pyloroplasty with vagotomy plus gastroenterostomy. He found that almost 90 percent of patients in both series had good results. The operative mortality was approximately the same, about 0.5 percent. The incidence of recurrent ulcer was about three percent in both groups. The only statistical difference between the two procedures was a slightly higher incidence of bilious vomiting following gastroenterostomy.9 Jordan compared a series of vagotomy and pyloroplasty with vagotomy and antrectomy. He concluded that although vagotomy with pyloroplasty gave a very high percentage of satisfactory results, (approximately 90 percent) vagotomy with antrectomy was the superior operation because of its lower recurrence rate. He cautioned, however, that the higher recurrence rate after vagotomy with pyloroplasty should be accepted in high risk cases where resection would cause an increase in morbidity and mortality.10 In a follow-up series comparing the same two types of operations, he reached almost the same conclusion, ie, there is no clear superiority of one operation over the other with respect to the occurrence of postoperative com plications and gastrointestinal symptoms. However, because of the better protection against recurrent ulcer provided by vagotomy plus antrectomy as compared to vagotomy plus pyloroplasty, he recommended the former over the latter.1 1 Thompson and Read recommend 901
the use of the Heineke-Milulicz pyloroplasty in routine cases because it is easier to perform. They recommend the Finney pyloroplasty be reserved for those patients with severe scarring and with bleeding in the distal duodenum. 1 2 The major controversy now in the treatment of duodenal ulceration is that of the procedure known as "highly selective vagotomy" or "parietal cell vagotomy." In this procedure there is a selective vagal denervation of the proximal stomach with preservation of the hepatic, celiac, and antral branches of the vagi. The antrum is not denervated, thus a drainage procedure is not required. Since the abdominal viscera have not been denervated, one should expect a marked lowering of uncomfortable postoperative symptoms such as "dumping and diarrhea." The results have been very encouraging and the mortality rate is extremely low. The incidence of "dumping and diarrhea" have been markedly reduced. The postoperative results, when based on the classification, were good to excellent in a high percentage of cases. Its major drawback has been the high incidence of recurrent ulcer. Kronborg in Denmark reported a significantly high figure of a 22 percent recurrent rate of duodenal ulcer following this procedure in cases followed from one to four years.1 3
Hemorrhage The major controversies in the treatment of hemorrhage have been well resolved. It is generally agreed that early operation is the procedure of choice. The question is, how early is early? It is generally agreed that the following factors are essential in defining the term early as it applies to the surgical treatment. (1) If the systolic pressure on admission is below 80 mm of mercury, emergency surgery is almost mandatory. (2) If more than six and certainly if eight transfusions are required in the first 24 hours, surgery is mandated immediately. Twenty-five to 30 transfusions over four or five days and being faced with operating on a continuing bleeder with attendant coagulapathy problems is thankfully a thing of the past. (3) The age of the patient. Advanced age usually requires early operation. Perhaps the most important controversy in the surgical treatment of the complication of hemorrhage is the 902
type of operation to be performed. Several studies have shown that vagotomy with pyloroplasty is a better procedure than gastric resection for bleeding from duodenal ulcer. Buckingham and Remine report that at the Mayo Clinic they have found no significant difference in mortality rate between vagotomy with pyloroplasty and gastric resection in the treatment of bleeding from duodenal ulcer. They found that in patients 60 years of age or over, vagotomy with pyloroplasty had fewer complications than with gastric resection. Additionally, the long-term results of both operations in patients over 60 are
similar.3 Perforation There is general agreement that surgery is the treatment of choice for perforation. As with the first two complications, it is the type of surgery that forms the basis for the controversy, ie, simple suturing vs definitive resection. One must use a balancing test and the factors to be considered are (1) the length of time of perforation, (2) the presence or absence of peritonitis and if present, the degree of its extent, and (3), the age and general condition of the patient. As a general rule, a young healthy patient with an early perforation and little soiling of the peritoneal cavity is an ideal candidate for definitive surgery ab initio.
Malignancy Here we are speaking primarily of malignant gastric ulcers and the only acceptable treatment is surgery. However, faced with the relentless, dismal five-year results in all series, the question arises as to the value of a radical resection with an aim for a cure. The main thrust in this area lies in early diagnosis. Because of the lack of specificity of gastric symptoms, patients are usually seen in an advanced stage of the disease. If a controversy does exist, it would be on the best way of applying the procedures currently used by the Japanese for early detection. The Japanese suffer from an inordinately high incidence of gastric cancer. They have instituted endoscopic examinations of the population, using fiber optic instruments on a mass basis. The results have been extremely encouraging with the detection of a high number of early asymptomatic gastric cancer.
Conclusion The major controversy in the treatment of peptic ulcer disease revolves around the best surgical procedure to be applied to the treatment of chronic duodenal ulcer. The operation of choice lies between vagotomy with drainage vs vagotomy with antrectomy. Good to excellent results can be obtained with both procedures. Vagotomy with drainage procedure has a high incidence of ulcer recurrence but, to its credit, has a low mortality rate. Vagotomy with antrectomy has a much lower recurrence rate but a higher mortality rate, albeit rather low. It raises the metaphysical question "how many ulcer recurrences equal one death?" Rather than attempting to resolve this question, it is far better, as is true with all surgery, to individualize the treatment, taking into consideration the age of the patient and the character of the duodenum.
Literature Cited 1. Post-Graduate Course Gastric Surgery: The Quiet Revolution. University of Colorado School of Medicine, N ovember 11, 12, 1976 2. Skillman JJ: Pathogenesis of peptic ulcer: A select review. Surgery 76:515, 1974 3. Buckingham JM, Re Mine WH: Results of emergency surgical management of hemorrhagic duodenal ulcer. Mayo Clin Proc 50:223-226, 1975 4. Cohen MM: Treatment and mortality of perforated peptic ulcer: A survey of 852 cases. Can Med Assoc J 105:263-269, 1971 5. Best CH, Taylor NB: Physiological Basis of Medical Practice, ed 3. Baltimore, Williams and Wilkins, 1943 6. Dragstedt LR: Peptic ulcer: An abnormality in gastric secretion. Am J Surg 117:143, 1969 7. Goligher JC, Pulvertaft CN, De Dombal FT, et al: Five-to eight-year results of Leeds/York controlled trial of elective surgery for duodenal ulcer. Br Med J 2:281-287, 1968 8. Goligher JC, Pulvertaft CN, Irvin TT, et al: Five-to eight-year results of truncal vagotomy with pyloroplasty for duodenal ulcer. Br Med J 1:7-13, 1972 9. Kennedy F, Mackay C, Bedi BS, et al: Truncal vagotomy and drainage for chronic duodenal ulcer disease: A controlled trial. Br Med J 2:71-75, 1973 10. Jordan PH, Condon RE: A prospective evaluation of vagotomy-pyloroplasty and vagotomy-antrectomy for treatment of duodenal ulcer. Ann Surg 172:547-563, 1970 11. Jordan PH: A followup report of a prospective evaluation of vagotomy-antrectomy for treatment of duodenal ulcer. Ann Surg 180:259-264, 1974 12. Thompson BE, Read PC: Long-term randomised prospective comparison of Finney vs Heineke-Mikulicz pyloroplasty in patients having vagotomy for peptic ulceration. Am J Surg 129:78-81, 1975 13. Kronborg 0, Madsen P: A controlled, randomised trial of highly selective vagotomy versus selective vagotomy andi pyloroplasty in the treatment of duodenal ulcer. Gut 16:268-271, 1975
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 12, 1977
Surgical treatment of peptic ulcer disease is the treatment of its complications. These complications - the same for all parts of the GI tract - are (1) intractability, (2) hemorrhage, (3) obstruction, (4) perforation, and (5) malignancy. During the past 25 years there have been major changes in the types of surgical approaches to each of the complications. Indeed, in November 1976, the University of Colorado School of Medicine presented a postgraduate course entitled Gastric Surgery: The Quiet Revolution.1 As with any revolution, albeit quiet, the basic thrust was the controversy over how best to deal with the problems at hand. Some of these controversies which are of current interest will be addressed.
Definitions The indications for operations in each of the complications presented are: 1. Intractability (50-5 5 percent of patients operated on)2
Read at the Sixth Annual Convention and Scientific Assembly of Region of the National Medical Association, Kiamesha Lake, New York, May 27-30, 1977. Requests for reprints should be addressed to Dr. Arthur T. Davidson, 1378 President Street, New York, NY 11213.
900
a. Ulcer must be confirmed - endoscopy if necessary b. Symptoms inhibit productive life c. Patient cannot/will not follow medical treatment d. Location of ulcer: Postbulbar or pyloric channel 2. Hemorrhage (20-25 percent of patients operated on)3 a. Massive bleeding after age 60 years b. Massive bleeding and previous major complication c. Repeated non-massive bleeding: Over age 60 years; Previous major complication; Patient will not/cannot follow treatment. 3. Obstruction (1-15 percent of patients operated on) a. No relief with 72 hours of nasogastric suction b. Previous major complication 4. Perforation (5-10 percent of patients operated on)4 a. Surgery, the treatment of choice 5. Malignancy (Almost 100 percent gastric in location and associated with absence of free acid) a. Surgery, the only treatment
Physiology Basic to the understanding of the pathogenesis of peptic ulceration is awareness of the production of acid by the stomach. It is interesting to note that other than the human stomach, the only organisms capable of producing a strong acid are certain mol-
luscs that produce sulphuric acid for defense purposes. These unicellular organisms elaborate a fluid with a low pH (as low as 1.0) in their vacuoles. The human stomach has scattered throughout its mucosa innumerable small tubular units which constitute the gastric glands. The glands anatomically consist of a narrow short superficial part, the neck, and a thicker longer portion, the body, which almost reaches to the muscularis mucosae. The blind extremity of these glands may be club shaped, indented, or branched. It has been estimated that these glands total about 35 million. The cellular structure of the glands is of great interest. The walls are composed of three types of cells: (1) chief cells of the neck or mucous neck cells, (2) chief cells of the body or zymogenic cells, and (3) parietal or border cells. The mucous cells secrete mucous only. The zymogenic cells secrete pepsin, a gastric enzyme that degrades proteins to peptones. It only acts in an acid medium. The parietal cells secrete hydrochloric acid. A very important anatomical point is that the gastric glands in the region of pylorus and those near the cardiac orifice contain only mucous cells and thus are capable of secreting only a mucus. The parietal cells are found only in those gastric glands located in the body and fundus. The hormone gastrin is produced by the glands in the pylorus or antrum of the stomach. The action of this hormone is one of the
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 12, 1977
two mechanisms responsible for the secretion of hydrochloric acid by the parietal cells in the fundus and body. The other mechanism is by vagal stimulation of the fundus and body of the stomach. Thus, one can see that the prevention of the secretion of hydrochloric acid lies in: (1) prevention of vagal stimulation and/or (2) removal of gastrin stimulation.5
Therapy for Complications In the treatment of peptic ulcer we must first differentiate between gastric and duodenal ulcers. Treatment of gastric ulcer - a totally different disease - offers no controversy as to the surgical treatment. If a diagnosis of chronic gastric ulcer is made, then all authorities agree that resection probably hemigastrectomy and vagotomy - is the treatment of choice. Past and current controversy continue debating the best surgical operation for the treatment of duodenal ulcer. Since duodenal ulcer results from a high concentration of gastric hydrochloric acid, the options for surgery are thus made more complex.6 Intractability The first operation used in the treatment of duodenal ulcer was the gastroenterostomy. This operation was very effective but was followed by the recurrence of the ulcer in approximately 30 percent of cases, when followed for long periods (up to 23 years). Noting the high incidence of recurrence, surgeons instituted a more radical operation, ie, a 60 to 80 percent distal subtotal gastrectomy. This proved effective because it removed (1) the antral gastrin mechanism and (2) a large part of the acid-producing parietal cell mass. Its drawbacks were that it caused a significant number of complications and mortalities. Dragstedt made a significant contribution to duodenal ulcer surgery by initiating the use of sectioning of the vagus nerves in order to decrease the stimulation of acid secretion.6 As a physiologist, he was aware of the significant role that (1) the vagi played in the stimulation of the secretion of acid by the parietal cells and (2) of the invariable association of the hypersecretion of acid with a duodenal ulcer. After noticing that his early cases had great difficulty with gastric emptying, he added gastroenterostomy to bilateral vagus section.
Since 1960, truncal vagotomy with either gastroenterostomy or pyloroplasty has achieved wide useage in England and the United States.7-10 It may well be that it is now the surgical procedure of choice for the treatment of duodenal ulcer. Its significant advantage is its low mortality rate but it has a significant incidence of ulcer recurrence - in the neighborhood of eight to ten percent. In an effort to combine the best of both worlds, surgeons began to combine vagotomy and antrectomy. It has a low recurrence rate, probably less than one percent, but it is associated with a rather high mortality rate (1.5 to 2 percent). One of the current controversies in the surgical treatment of duodenal ulcer disease is whether to use vagotomy with a drainage procedure or vagotomy with antrectomy. When analyzing the effectiveness of vagotomy plus gastroenterostomy or antrectomy versus subtotal gastrectomy, one of the most comprehensive and detailed comparisons was presented by Goligher7 of England. He used as his evaluation yardstick the following classification: 1. Excellent - No symptoms 2. Very good - Occasional mild symptoms 3. Satisfactory - Moderate symptoms - some discomfort 4. Unsatisfactory - Moderate to severe symptoms which interfere considerably with work or enjoyment of life. Both patient and doctor dissatisfied with results. Includes all cases of proven recurrent ulcers. A three-year follow-up of approximately 634 cases revealed that subtotal gastrectomy had the least number of cases in category 4. However, when comparing the number of cases in categories 1 and 2, vagotomy and antrectomy gave slightly better results than subtotal gastrectomy (78 to 77 percent). Vagotomy and gastroenterostomy had 70 percent of its cases in categories 1 and 2. Subtotal gastrectomy had the lowest incidence (two to five percent) of recurrent ulceration over a period of five to eight years. The incidence of recurrence after vagotomy and gastroenterostomy was approximately seven to ten percent. And, after vagotomy and antrectomy, Goligher reported the rather high figures of two to six percent. This does not compare with most American series where the recur-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 12 1977
rence rate, following vagotomy and antrectomy, has the extraordinarily low recurrence rate of less than one
percent.7 Malabsorption and metabolic ill effects were greater following gastrectomy and vagotomy with antrectomy than with vagotomy with gastroenterostomy. Subtotal gastrectomy had the highest mortality rate (one to two percent) followed by vagotomy and antrectomy. Vagotomy with gastroenterostomy had the lowest mortality rate (less than 0.5 percent).7 In a later series, Goligher compared the results of vagotomy with pyloroplasty with the three procedures. He found that recurrent ulceration was much higher after vagotomy with pyloroplasty than with the other three
procedures.8 Kennedy of England compared vagotomy plus pyloroplasty with vagotomy plus gastroenterostomy. He found that almost 90 percent of patients in both series had good results. The operative mortality was approximately the same, about 0.5 percent. The incidence of recurrent ulcer was about three percent in both groups. The only statistical difference between the two procedures was a slightly higher incidence of bilious vomiting following gastroenterostomy.9 Jordan compared a series of vagotomy and pyloroplasty with vagotomy and antrectomy. He concluded that although vagotomy with pyloroplasty gave a very high percentage of satisfactory results, (approximately 90 percent) vagotomy with antrectomy was the superior operation because of its lower recurrence rate. He cautioned, however, that the higher recurrence rate after vagotomy with pyloroplasty should be accepted in high risk cases where resection would cause an increase in morbidity and mortality.10 In a follow-up series comparing the same two types of operations, he reached almost the same conclusion, ie, there is no clear superiority of one operation over the other with respect to the occurrence of postoperative com plications and gastrointestinal symptoms. However, because of the better protection against recurrent ulcer provided by vagotomy plus antrectomy as compared to vagotomy plus pyloroplasty, he recommended the former over the latter.1 1 Thompson and Read recommend 901
the use of the Heineke-Milulicz pyloroplasty in routine cases because it is easier to perform. They recommend the Finney pyloroplasty be reserved for those patients with severe scarring and with bleeding in the distal duodenum. 1 2 The major controversy now in the treatment of duodenal ulceration is that of the procedure known as "highly selective vagotomy" or "parietal cell vagotomy." In this procedure there is a selective vagal denervation of the proximal stomach with preservation of the hepatic, celiac, and antral branches of the vagi. The antrum is not denervated, thus a drainage procedure is not required. Since the abdominal viscera have not been denervated, one should expect a marked lowering of uncomfortable postoperative symptoms such as "dumping and diarrhea." The results have been very encouraging and the mortality rate is extremely low. The incidence of "dumping and diarrhea" have been markedly reduced. The postoperative results, when based on the classification, were good to excellent in a high percentage of cases. Its major drawback has been the high incidence of recurrent ulcer. Kronborg in Denmark reported a significantly high figure of a 22 percent recurrent rate of duodenal ulcer following this procedure in cases followed from one to four years.1 3
Hemorrhage The major controversies in the treatment of hemorrhage have been well resolved. It is generally agreed that early operation is the procedure of choice. The question is, how early is early? It is generally agreed that the following factors are essential in defining the term early as it applies to the surgical treatment. (1) If the systolic pressure on admission is below 80 mm of mercury, emergency surgery is almost mandatory. (2) If more than six and certainly if eight transfusions are required in the first 24 hours, surgery is mandated immediately. Twenty-five to 30 transfusions over four or five days and being faced with operating on a continuing bleeder with attendant coagulapathy problems is thankfully a thing of the past. (3) The age of the patient. Advanced age usually requires early operation. Perhaps the most important controversy in the surgical treatment of the complication of hemorrhage is the 902
type of operation to be performed. Several studies have shown that vagotomy with pyloroplasty is a better procedure than gastric resection for bleeding from duodenal ulcer. Buckingham and Remine report that at the Mayo Clinic they have found no significant difference in mortality rate between vagotomy with pyloroplasty and gastric resection in the treatment of bleeding from duodenal ulcer. They found that in patients 60 years of age or over, vagotomy with pyloroplasty had fewer complications than with gastric resection. Additionally, the long-term results of both operations in patients over 60 are
similar.3 Perforation There is general agreement that surgery is the treatment of choice for perforation. As with the first two complications, it is the type of surgery that forms the basis for the controversy, ie, simple suturing vs definitive resection. One must use a balancing test and the factors to be considered are (1) the length of time of perforation, (2) the presence or absence of peritonitis and if present, the degree of its extent, and (3), the age and general condition of the patient. As a general rule, a young healthy patient with an early perforation and little soiling of the peritoneal cavity is an ideal candidate for definitive surgery ab initio.
Malignancy Here we are speaking primarily of malignant gastric ulcers and the only acceptable treatment is surgery. However, faced with the relentless, dismal five-year results in all series, the question arises as to the value of a radical resection with an aim for a cure. The main thrust in this area lies in early diagnosis. Because of the lack of specificity of gastric symptoms, patients are usually seen in an advanced stage of the disease. If a controversy does exist, it would be on the best way of applying the procedures currently used by the Japanese for early detection. The Japanese suffer from an inordinately high incidence of gastric cancer. They have instituted endoscopic examinations of the population, using fiber optic instruments on a mass basis. The results have been extremely encouraging with the detection of a high number of early asymptomatic gastric cancer.
Conclusion The major controversy in the treatment of peptic ulcer disease revolves around the best surgical procedure to be applied to the treatment of chronic duodenal ulcer. The operation of choice lies between vagotomy with drainage vs vagotomy with antrectomy. Good to excellent results can be obtained with both procedures. Vagotomy with drainage procedure has a high incidence of ulcer recurrence but, to its credit, has a low mortality rate. Vagotomy with antrectomy has a much lower recurrence rate but a higher mortality rate, albeit rather low. It raises the metaphysical question "how many ulcer recurrences equal one death?" Rather than attempting to resolve this question, it is far better, as is true with all surgery, to individualize the treatment, taking into consideration the age of the patient and the character of the duodenum.
Literature Cited 1. Post-Graduate Course Gastric Surgery: The Quiet Revolution. University of Colorado School of Medicine, N ovember 11, 12, 1976 2. Skillman JJ: Pathogenesis of peptic ulcer: A select review. Surgery 76:515, 1974 3. Buckingham JM, Re Mine WH: Results of emergency surgical management of hemorrhagic duodenal ulcer. Mayo Clin Proc 50:223-226, 1975 4. Cohen MM: Treatment and mortality of perforated peptic ulcer: A survey of 852 cases. Can Med Assoc J 105:263-269, 1971 5. Best CH, Taylor NB: Physiological Basis of Medical Practice, ed 3. Baltimore, Williams and Wilkins, 1943 6. Dragstedt LR: Peptic ulcer: An abnormality in gastric secretion. Am J Surg 117:143, 1969 7. Goligher JC, Pulvertaft CN, De Dombal FT, et al: Five-to eight-year results of Leeds/York controlled trial of elective surgery for duodenal ulcer. Br Med J 2:281-287, 1968 8. Goligher JC, Pulvertaft CN, Irvin TT, et al: Five-to eight-year results of truncal vagotomy with pyloroplasty for duodenal ulcer. Br Med J 1:7-13, 1972 9. Kennedy F, Mackay C, Bedi BS, et al: Truncal vagotomy and drainage for chronic duodenal ulcer disease: A controlled trial. Br Med J 2:71-75, 1973 10. Jordan PH, Condon RE: A prospective evaluation of vagotomy-pyloroplasty and vagotomy-antrectomy for treatment of duodenal ulcer. Ann Surg 172:547-563, 1970 11. Jordan PH: A followup report of a prospective evaluation of vagotomy-antrectomy for treatment of duodenal ulcer. Ann Surg 180:259-264, 1974 12. Thompson BE, Read PC: Long-term randomised prospective comparison of Finney vs Heineke-Mikulicz pyloroplasty in patients having vagotomy for peptic ulceration. Am J Surg 129:78-81, 1975 13. Kronborg 0, Madsen P: A controlled, randomised trial of highly selective vagotomy versus selective vagotomy andi pyloroplasty in the treatment of duodenal ulcer. Gut 16:268-271, 1975
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 12, 1977
