Br. J. Surg. Vol. 64 (1977) 39-41
Gastric ulceration after vagotomy for duodenal ulcer JACINTO DE M I G U E L * SUMMARY
Fourteen instances of gastric ulceration following 415 vagotomies for duodenal ulcer have been reviewed with special reference to the relative incidence of this complication after diferent types of vagotomy, and to its clinical and radiologicalfeatures and treatment. The aetiology is discussed. WHEN Polya subtotal gastrectomy was the operation of choice for duodenal ulcer, recurrent ulcer, if encountered, was found to develop usually in the region of the gastrojejunal anastomosis and only very rarely in the stomach itself (Fig. 1). Since the stomachpreserving operation of vagotomy with or without drainage has become the usual procedure for duodenal ulcer during the past two decades, the chances of recurrence in the form of gastric ulceration would seem to have increased. The purpose of the present paper is to review the 14 cases of gastric ulceration arising after 415 vagotomy operations performed by the author up to 1970.
Findings Incidence in relation to type of vagotomy The frequency of gastric ulceration according to the type of vagotomy performed is analysed in Table I. It will be seen that whilst the overall incidence was 3.4 per cent there was little differencein the frequencies after the three operative methods. The small number of cases for two of the procedures makes the slightly higher incidence of 4.8 per cent after selectivevagotomy without drainage statistically insignificant. Clinical and radiological manifestations Recurrent epigastric pain of ulcer type was a prominent feature in all the patients but one. In 5 it was associated with bleeding, which in 2 cases was massive. The ulcer was demonstrated on X-ray examination in 12 cases. (Two patients were operated on as emergencies for haemorrhage and therefore barium studies were not available.) The ulcer was located on the lesser curve in 8, mostly near the incisura angularis, in the antrum in 2 and in the immediate pre-pyloric region in 2. The average size of the ulcer craters shown radiologically was 1.6 cm in diameter, but in 3 cases it was 25-3 cm. Time interval between original operation and presentation of recurrence Though the average time for gastric ulcers to be diagnosed after vagotomy was just over 4 years, in 4 cases it was not until 6, 6.5,8 and 9 years respectively the recurrence was detected (Table ZI). that
Fig. 1. Barium meal examination showing an anastomotic ulcer after Billroth I gastrectomy for duodenal ulcer. Table I: GASTRIC ULCER RECURRENCES FOLLOWING DIFFERENT TYPES OF VAGOTOMY FOR DUODENAL ULCER No. of Gastric recurrence Original oueration uatients No. Per cent Vagotomy with.gastro63 2 3.2 enterostomy Vagotomy with pyloroplasty 31 1 10 3.2 Selective vagotomy without 41 2 4.9 drainage Total 415 14* 3.4
* Males 12. females 2. Emptying of stomach at time of detection of recurrence In order to study gastric emptying in these patients and to detect retention a special radiological examination was conducted after a solid meal containing some barium. Gastric retention was considered to be present if barium was still demonstrable in the
* Address for reprints: Paseo de Zorilla, 30, Valladolid, Spain.
40
Jacinto de Miguel
a
b
Fig. 2. a, Barium meal film in 1969, 2 years after vagotomy and pyloroplasty for duodenal ulcer, showing a gastric ulcer on the lesser curve of the stomach. 6, In 1973 the gastric ulcer was completely healed. (On repeat examination in 1976 it was still healed.)
Table 11: INTERVAL BETWEEN ORIGINAL OPERATION AND RECURRENCE, PRESENCE OF GASTRIC RETENTION, TREATMENT AND OUTCOME Interval between Presence and operation and severity of Treatment of Condition at Original operation recurrence (yr) gastric retention recurrence latest follow-up Vagotomy with gastro-enterostomy 1.2 Not tested Medical Good at 7 yr 9.0 0 Medica 1 Good at 4.5 yr 6.5 0 Medical Good at 4.5 yr 6.0 Gastrectomy Good 5.5 Medical Grater still present 8.0 Not tested Medical Crater still present Vagotomy with pyloroplasty 5.0 Not tested Gastrectomy Good 2.2 0 Medical Good at 5.5 yr Crater still present 2.0 Medical 4.0 Gastrectomy Good 3.6 Not tested Gastrectomy Good Good at 5 yr 3.0 Medical Selective vagotomy without drainage 4.0 Not tested Gastrectomy Good 3.0 Castrectomy Good
+ +
++ +++ ++ ++
stomach after 6 hours, and varying degrees of severity of retention were arbitrarily recognized as follows : 0 = No barium evident in stomach at 6 hours. = Barium present in stomach at 7 hours. + = Barium present in stomach at 8 hours. + = Barium present in stomach at more than 8 hours. Applying this system of grading to the 9 patients who were subjected to the special X-ray study revealed that 3 had no gastric retention (0), 2 had mild retention
++
+ +
(+), 3 a moderate degree of retention (+ +) and one had severe retention (+ +) (Table ZZ).
+
Treatment and outcome (Table ZZ) In 2 patients whose recurrence presented by causing severe haematemesis the treatment was by emergency gastrectomy. In the remaining 12 patients whose gastric ulcer appeared more insidiously, the initial treatment was medical, with subsidence of symptoms and
Gastric ulceration after vagotomy radiologically demonstrated healing of the lesion in 5-a result that has been maintained on follow-up for more than 4 years (Fig. 2). Unfortunately, in 7 cases the results of conservative management were not satisfactory and, because of the persistence of severe pain or failure of complete healing of the ulcer crater, gastric resection was performed in 4 and has now been advised in another 3. Discussion The development of a benign gastric ulcer after truncal vagotomy alone for duodenal ulcer was soon recognized by Dragstedt as a complication of this initial form of vagotomy (Dragstedt et al., 1949). The first reported case so complicated was in a patient who underwent a transthoracic vagotomy without gastric drainage for duodenal ulcer in January 1943. Four years later, when the duodenal ulcer was well healed, he was found to have a large gastric ulcer penetrating into the pancreas for which a partial gastrectomy was performed. Subsequently similar complicating gastric ulcers were demonstrated by Dragstedt’s group in 3 per cent of their series of 158 patients operated on by truncal vagotomy without drainage for duodenal ulcer (Oberhelman and Dragstedt, 1955). In all these recurrent cases the vagotomy had been shown to be complete by a negative response to the Hollander insulin test. However, a variable degree of gastric retention was said to be present in all of them due to pyloric dysfunction, and this alleged gastric retention was considered by Dragstedt to be responsible for the production of the gastric ulceration by causing antral stimulation and release of gastrin with resulting secretion of acid and pepsin by the parietal cell mass. With the addition of a complementary drainage procedure at the time of vagotomy it was thought that the complication of gastric ulceration would be effectively prevented, but Burge (1960) reported 10-yearfollow-up incidences of gastric ulcer recurrence of 0.7 and 2.3 per cent after vagotomy and gastroenterostomy and vagotomy and pyloroplasty respectively for duodenal ulcer. Bank et al. (1969) published details of 9 patients who developed gastric ulcer after vagotomy and drainage for duodenal ulcer. It will also be noted that in the present study (Table I ) , though the incidence of gastric ulcer after vagotomy and drainage was lower than that after selective vagotomy without drainage (3-2 as against 4.9 per cent), the difference was not statistically significant. On Dragstedt’s hypothesis of aetiology (Oberhelman and Dragstedt, 1955) it is difficult to explain the development of gastric ulcer following vagotomy with a drainage procedure, unless it is postulated that some degree of gastric retention may persist even after
41
gastro-enterostomy or pyloroplasty. In this connection it is interesting to observe that on radiological examination after a special food/barium meal in 8 of the patients in this series with recurrent gastric ulceration after vagotomy and drainage 5 had some degree of gastric retention (Table ZZ). Of the 2 patients with gastric ulceration after selective vagotomy without drainage, one showed gastric retention on radiological examination and one appeared to have normal emptying. No cases of duodenal ulcer treated by the newly introduced operation of proximal gastric (parietal cell) vagotomy without drainage were included in this study, but it will be interesting to see in due course what incidence of gastric ulcer arises in the current series of patients with duodenal ulcer being treated by the author with this procedure. The average length of time taken for gastric ulcers to develop in this series after vagotomy for duodenal ulcer was 4 years, but in some cases the first manifestation of the gastric ulcer was 8 and 9 years. Clearly a long period of follow-up is necessary to obtain a full measure of the incidence of this complication. In the present study all the patients were traced for at least 5 years and many of them for much longer, but possibly an even longer period of follow-up might disclose further examples of this complication. Though 6 of the 14 patients now reported have had to undergo further surgical treatment for their gastric ulceration and in another 3 reoperation has been advised, it is worth bearing in mind that in 5 cases the ulcer healed on medical measures and this cure has been maintained in all of them for no less than 4 years. This experience is perhaps too small to permit any very firm conclusions regarding therapy, but it seems to indicate the value of an initial trial of medical treatment before resorting to surgery, provided that there are no cogent contraindications. References BANK s., MARKS I. N., LOUW J. H. et al. (1969) Nine cases of gastric ulcer after vagotomy and drainage for duodenal ulcer. Gut 10,460-468. BURGE H. w. (1960) Vagal nerve section in chronic duodenal ulceration. Ann. R. Coll. Surg. Engl. 26,231-244.
and FRITZ J. M. (1949) Recurrence of gastric ulcer after complete vagotomy. Ann. Surg. 130,843-854. OBERHELMAN H. A. and DRAGSTEDT L. R. (1955) New physiologic concepts related to the surgical treatment of duodenal ulcer by vagotomy and gastroenterostomy. Surg. Gynecol. Obstet. 101,
DRAGSTEDT L. R., CAMP E. H.
194-200.
Gastric ulceration after vagotomy for duodenal ulcer JACINTO DE M I G U E L * SUMMARY
Fourteen instances of gastric ulceration following 415 vagotomies for duodenal ulcer have been reviewed with special reference to the relative incidence of this complication after diferent types of vagotomy, and to its clinical and radiologicalfeatures and treatment. The aetiology is discussed. WHEN Polya subtotal gastrectomy was the operation of choice for duodenal ulcer, recurrent ulcer, if encountered, was found to develop usually in the region of the gastrojejunal anastomosis and only very rarely in the stomach itself (Fig. 1). Since the stomachpreserving operation of vagotomy with or without drainage has become the usual procedure for duodenal ulcer during the past two decades, the chances of recurrence in the form of gastric ulceration would seem to have increased. The purpose of the present paper is to review the 14 cases of gastric ulceration arising after 415 vagotomy operations performed by the author up to 1970.
Findings Incidence in relation to type of vagotomy The frequency of gastric ulceration according to the type of vagotomy performed is analysed in Table I. It will be seen that whilst the overall incidence was 3.4 per cent there was little differencein the frequencies after the three operative methods. The small number of cases for two of the procedures makes the slightly higher incidence of 4.8 per cent after selectivevagotomy without drainage statistically insignificant. Clinical and radiological manifestations Recurrent epigastric pain of ulcer type was a prominent feature in all the patients but one. In 5 it was associated with bleeding, which in 2 cases was massive. The ulcer was demonstrated on X-ray examination in 12 cases. (Two patients were operated on as emergencies for haemorrhage and therefore barium studies were not available.) The ulcer was located on the lesser curve in 8, mostly near the incisura angularis, in the antrum in 2 and in the immediate pre-pyloric region in 2. The average size of the ulcer craters shown radiologically was 1.6 cm in diameter, but in 3 cases it was 25-3 cm. Time interval between original operation and presentation of recurrence Though the average time for gastric ulcers to be diagnosed after vagotomy was just over 4 years, in 4 cases it was not until 6, 6.5,8 and 9 years respectively the recurrence was detected (Table ZI). that
Fig. 1. Barium meal examination showing an anastomotic ulcer after Billroth I gastrectomy for duodenal ulcer. Table I: GASTRIC ULCER RECURRENCES FOLLOWING DIFFERENT TYPES OF VAGOTOMY FOR DUODENAL ULCER No. of Gastric recurrence Original oueration uatients No. Per cent Vagotomy with.gastro63 2 3.2 enterostomy Vagotomy with pyloroplasty 31 1 10 3.2 Selective vagotomy without 41 2 4.9 drainage Total 415 14* 3.4
* Males 12. females 2. Emptying of stomach at time of detection of recurrence In order to study gastric emptying in these patients and to detect retention a special radiological examination was conducted after a solid meal containing some barium. Gastric retention was considered to be present if barium was still demonstrable in the
* Address for reprints: Paseo de Zorilla, 30, Valladolid, Spain.
40
Jacinto de Miguel
a
b
Fig. 2. a, Barium meal film in 1969, 2 years after vagotomy and pyloroplasty for duodenal ulcer, showing a gastric ulcer on the lesser curve of the stomach. 6, In 1973 the gastric ulcer was completely healed. (On repeat examination in 1976 it was still healed.)
Table 11: INTERVAL BETWEEN ORIGINAL OPERATION AND RECURRENCE, PRESENCE OF GASTRIC RETENTION, TREATMENT AND OUTCOME Interval between Presence and operation and severity of Treatment of Condition at Original operation recurrence (yr) gastric retention recurrence latest follow-up Vagotomy with gastro-enterostomy 1.2 Not tested Medical Good at 7 yr 9.0 0 Medica 1 Good at 4.5 yr 6.5 0 Medical Good at 4.5 yr 6.0 Gastrectomy Good 5.5 Medical Grater still present 8.0 Not tested Medical Crater still present Vagotomy with pyloroplasty 5.0 Not tested Gastrectomy Good 2.2 0 Medical Good at 5.5 yr Crater still present 2.0 Medical 4.0 Gastrectomy Good 3.6 Not tested Gastrectomy Good Good at 5 yr 3.0 Medical Selective vagotomy without drainage 4.0 Not tested Gastrectomy Good 3.0 Castrectomy Good
+ +
++ +++ ++ ++
stomach after 6 hours, and varying degrees of severity of retention were arbitrarily recognized as follows : 0 = No barium evident in stomach at 6 hours. = Barium present in stomach at 7 hours. + = Barium present in stomach at 8 hours. + = Barium present in stomach at more than 8 hours. Applying this system of grading to the 9 patients who were subjected to the special X-ray study revealed that 3 had no gastric retention (0), 2 had mild retention
++
+ +
(+), 3 a moderate degree of retention (+ +) and one had severe retention (+ +) (Table ZZ).
+
Treatment and outcome (Table ZZ) In 2 patients whose recurrence presented by causing severe haematemesis the treatment was by emergency gastrectomy. In the remaining 12 patients whose gastric ulcer appeared more insidiously, the initial treatment was medical, with subsidence of symptoms and
Gastric ulceration after vagotomy radiologically demonstrated healing of the lesion in 5-a result that has been maintained on follow-up for more than 4 years (Fig. 2). Unfortunately, in 7 cases the results of conservative management were not satisfactory and, because of the persistence of severe pain or failure of complete healing of the ulcer crater, gastric resection was performed in 4 and has now been advised in another 3. Discussion The development of a benign gastric ulcer after truncal vagotomy alone for duodenal ulcer was soon recognized by Dragstedt as a complication of this initial form of vagotomy (Dragstedt et al., 1949). The first reported case so complicated was in a patient who underwent a transthoracic vagotomy without gastric drainage for duodenal ulcer in January 1943. Four years later, when the duodenal ulcer was well healed, he was found to have a large gastric ulcer penetrating into the pancreas for which a partial gastrectomy was performed. Subsequently similar complicating gastric ulcers were demonstrated by Dragstedt’s group in 3 per cent of their series of 158 patients operated on by truncal vagotomy without drainage for duodenal ulcer (Oberhelman and Dragstedt, 1955). In all these recurrent cases the vagotomy had been shown to be complete by a negative response to the Hollander insulin test. However, a variable degree of gastric retention was said to be present in all of them due to pyloric dysfunction, and this alleged gastric retention was considered by Dragstedt to be responsible for the production of the gastric ulceration by causing antral stimulation and release of gastrin with resulting secretion of acid and pepsin by the parietal cell mass. With the addition of a complementary drainage procedure at the time of vagotomy it was thought that the complication of gastric ulceration would be effectively prevented, but Burge (1960) reported 10-yearfollow-up incidences of gastric ulcer recurrence of 0.7 and 2.3 per cent after vagotomy and gastroenterostomy and vagotomy and pyloroplasty respectively for duodenal ulcer. Bank et al. (1969) published details of 9 patients who developed gastric ulcer after vagotomy and drainage for duodenal ulcer. It will also be noted that in the present study (Table I ) , though the incidence of gastric ulcer after vagotomy and drainage was lower than that after selective vagotomy without drainage (3-2 as against 4.9 per cent), the difference was not statistically significant. On Dragstedt’s hypothesis of aetiology (Oberhelman and Dragstedt, 1955) it is difficult to explain the development of gastric ulcer following vagotomy with a drainage procedure, unless it is postulated that some degree of gastric retention may persist even after
41
gastro-enterostomy or pyloroplasty. In this connection it is interesting to observe that on radiological examination after a special food/barium meal in 8 of the patients in this series with recurrent gastric ulceration after vagotomy and drainage 5 had some degree of gastric retention (Table ZZ). Of the 2 patients with gastric ulceration after selective vagotomy without drainage, one showed gastric retention on radiological examination and one appeared to have normal emptying. No cases of duodenal ulcer treated by the newly introduced operation of proximal gastric (parietal cell) vagotomy without drainage were included in this study, but it will be interesting to see in due course what incidence of gastric ulcer arises in the current series of patients with duodenal ulcer being treated by the author with this procedure. The average length of time taken for gastric ulcers to develop in this series after vagotomy for duodenal ulcer was 4 years, but in some cases the first manifestation of the gastric ulcer was 8 and 9 years. Clearly a long period of follow-up is necessary to obtain a full measure of the incidence of this complication. In the present study all the patients were traced for at least 5 years and many of them for much longer, but possibly an even longer period of follow-up might disclose further examples of this complication. Though 6 of the 14 patients now reported have had to undergo further surgical treatment for their gastric ulceration and in another 3 reoperation has been advised, it is worth bearing in mind that in 5 cases the ulcer healed on medical measures and this cure has been maintained in all of them for no less than 4 years. This experience is perhaps too small to permit any very firm conclusions regarding therapy, but it seems to indicate the value of an initial trial of medical treatment before resorting to surgery, provided that there are no cogent contraindications. References BANK s., MARKS I. N., LOUW J. H. et al. (1969) Nine cases of gastric ulcer after vagotomy and drainage for duodenal ulcer. Gut 10,460-468. BURGE H. w. (1960) Vagal nerve section in chronic duodenal ulceration. Ann. R. Coll. Surg. Engl. 26,231-244.
and FRITZ J. M. (1949) Recurrence of gastric ulcer after complete vagotomy. Ann. Surg. 130,843-854. OBERHELMAN H. A. and DRAGSTEDT L. R. (1955) New physiologic concepts related to the surgical treatment of duodenal ulcer by vagotomy and gastroenterostomy. Surg. Gynecol. Obstet. 101,
DRAGSTEDT L. R., CAMP E. H.
194-200.
