Br. J. Surg. Vol. 62 (1975) 875-878
Recurrence of gastric ulcer after selective vagotomy and pyloroplasty for chronic uncomplicated gastric ulcer: a 5-10 year follow-up JACINTO DE M I G U E L * SUMMARY
Selective vagotomy and pyloroplasty were used in the surgical treatment of 73 patients with benign gastric ulcer between July 1964 and February 1970. Over the long period of observation recurrence of the gastric ulcer was found in 13 patients (191 per cent). This complication occurred equally commonly after treatment of primary and secondary gastric ulcers and was twice as frequent in women as in men. Possible reasons for these recurrences are discussed. It is concluded that vagotomy and pyloroplasty cure benign gastric ulcer in about 80 per cent of patients, and this should be taken into account in the choice of surgical treatment, especially in patients in whom a gastrectomy might put the patient’s life at risk. However, because of the high recurrence rate, it is doubtful whether this operation should be considered the treatment of choice for all cases of gastric ulcer. PARTIAL gastrectomy remains the favourite operation with most surgeons for the treatment of gastric ulcer, but in recent years vagotomy and pyloroplasty have been used as an alternative in several centres. Reports on the results after vagotomy and pyloroplasty are most conflicting. In particular, the recurrence rate has varied widely from centre to centre. This paper presents a review of observations on recurrent ulceration after vagotomy and pyloroplasty in the treatment of gastric ulcer. Patients and methods From July 1964 to February 1970, 73 patients with chronic uncomplicated gastric ulcer were operated upon personally by bilateral selective vagotomy and pyloroplasty. Patients having emergency operations, patients with ‘acute’ or ‘stress’ ulcer and those in whom the crater proved to be malignant were excluded from the study. In the course of the operation special care was taken to spare the hepatic and coeliac branches but to cut all the vagal branches passing to the stomach. The associated pyloroplasty was of Weinberg or Finney type and was performed in one layer with interrupted sutures. In most cases the gastric ulcer was biopsied by the four-quadrant technique and the pieces were submitted to immediate frozen section histological examination. It was also possible to carry out serial radiological observations during the postoperative period to follow the healing of the ulcer crater. It was found in nearly every case that the ulcer took about
2-3 weeks to disappear after the operation, no matter how big it had been originally. Later in the series the ulcers were excised completely from inside the stomach and the defect in the mucosa was closed with interrupted catgut sutures.
Follow-up studies The majority of the patients were followed up every 1 or 2 years. The interim results have been published previously (de Miguel, 1968, 1970, 1972). The latest of these assessments was carried out in the weeks prior to the preparation of this paper. Details of the followup are shown in Table I. Of the 3 unrelated deaths, one was due to a road accident 3&years after operation. Two other patients died 2 months and 1 month after the operation, from multiple emboli secondary to mitral stenosis and from probable coronary occlusion respectively. Three patients have been lost to follow-up. The remaining 67 patients (54 males and 13 females) were assessed as shown in Table II. Table I: STATE OF FOLLOW-UP 5-10 YEARS AFTER OPERATION 13 Total number of patients operated on Operative deaths 0 Late unrelated death 3 Lost to follow-up 3 Cases traced 5-10 years after operation 67 (96%) Table 11: METHOD OF ASSESSMENT ON FOLLOW-UP AT 5-10 YEARS Personal interview alone 19 Personal interview plus X-ray examination 32 Postal questionnaire 16
Fifty-one of the 67 patients attended for personal interview. Nineteen of them were found to be asymptomatic and no special investigation was considered necessary in these cases. The remaining 32 were submitted to radiological study, including all the patients in the series who had major or minor gastric symptoms. Some patients who had complained of symptoms related to the stomach and who were assessed by means of a postal questionnaire in the first instance were advised to come to the clinic for a personal interview and complementary radiological studies.
* Paseo De Zorrilla 30, Valladolid, Spain. 875
Jacinto de Miguel Ulcers were considered ‘primary’ when unassociated with duodenal ulcer, and ‘secondary’ when a duodenal deformity or an active duodenal ulcer was observed radiologically or at operation. Of the 67 traced cases, 45 had had ‘primary’ ulcers and 22 ‘secondary’ ulcers.
Recurrent gastric ulcer The recognition of this complication was generally easy. Most of the recurrences had been diagnosed at some time during the follow-up period but some of them were detected only at the latest assessment. Details of the recurrent ulcers according to the sex of the patient and the type of ulcer are shown in Table IIZ. The incidence of recurrence after operation for ‘secondary’ gastric ulcer was found to be the same as that after operation for ‘primary’ gastric ulcer. Recurrent ulceration was twice as frequent in women as in men. Tahle 111: RECURRENCE OF GASTRIC ULCER AFTER SELECTIVE VAGOTOMY AND PYLOROPLASTY FOR GASTRIC ULCER Recurrence No. of cases No. % Type of ulcer Male 35 6 17.1 Primary Female 10 3 30.0 3 15.8 Secondary I 33.3 13 19.1 Both types 67
Some aspects of recurrent ulceration Recurrences were analysed with respect to the time which had elapsed between the operation and the patient’s presentation with recurrence, the site of the recurrence, the type of pyloroplasty which had been performed, the degree of gastric retention, if any, and whether the ulcer had been left in situ or had been excised at the first operation (Table ZV). In 3 patients recurrence was diagnosed before 1 year had elapsed after the first operation. Indeed, none of the 3 patients was free of symptoms at any time and, though the ulcer crater was not detected radiologically for several months, it was suspected that in fact the ulcer had never healed. In 10 patients recurrence took place between 2 and 7 years after operation, with an average of 5 years. Again, in this regard, no differences were observed between primary and secondary gastric ulcers. In each case recurrence appeared in the same place as the original ulcer. Both types of pyloroplasty, Finney and Weinberg, were followed by this complication in similar proportions. In nearly all the patients with recurrent ulceration, the gastric ulcer has been left in situ at the first operation, but in 1 case it had been excised completely and the ulcer had reappeared in the same site. In order to study gastric emptying and detect any gastric retention a food-barium meal was given to the patient. Gastric retention was diagnosed empirically
Table IV: DETAILS OF PATIENTS WHO DEVELOPED RECURRENT ULCERATION Time interval before presentation Type of Ulcer excised Type of ulcer with recurrence Site of recurrence pyloroplasty or left in situ P S P P P S P S S P P P P
4.7 yr 5 4 yr 5.5 yr 10 mth 7.1 yf 3.0 yr 7 mth 4.4 yr 8 mth 4.6 yr 2.0 yr 6.9 yr 3.0 yr
Same (incisura) Same (lesser curve) Same (incisura) Same (incisura) Same (lesser curve) Same (incisura) Same (antrum) Same (incisura) Same (incisura) Same (lesser curve) Same (antrum) Same (lesser curve) Same (incisura)
w F
F W W F F
F F W F F F
Left Left Left Left Left Left Left Left Excised Left Left Left Left
Gastric retention
Hollander insulin test
+++
-
0 ?
++A
0
++
++t
t
+
-
++ ++ + 0
0
P, Primary ulcer; S, secondary ulcer; W, Weinberg pyloroplasty; F, Finney pyloroplasty. Table V: SYMPTOMATIC PROGRESS AND TREATMENT OF PATIENTS WITH RECURRENT GASTRIC ULCER Result a t latest Case Symptoms of recurrence Treatment of recurrence follow-up Observations Partial gastrectomy 1 Continuous pain Good Medica 1 Good 2 Mild pain No symptoms at >2$ yr Partial gastrectomy 3 Continuous pain Good 4 Continuous pain Partial gastrectomy Good 5 Mild pain Medical Good 6 Mild pain Medical Fair Crater still present 7 Continuous pain Antrectomy Good 8 Mild pain for 8 d Medical Good NO symptoms at > 2 yr 5, Persistent pain soon after the operation Antrectomy Good 10 Pain for 2 mth Medical Good 11 Continuous pain Antrectomy Good 12 Continuous pain for 3 mth Medical Fair Crater still present Medical Good 13 Mild pain
876
Gastric ulcer recurrence when barium was detected within the stomach after 6 hours. Different grades of retention were classified as follows: 0, N o barium seen at 6 hours. +, Barium evident at 7 hours. + +, Barium evident at 8 hours. + + +, Barium evident at more than 8 hours. When such a classification was used 3 patients showed marked gastric retention ( + +), 3 had a moderate degree of retention (+ +) and 2 had mild retention (+). In 4 patients no gastric retention (0) was found. One patient was not studied. It should be added that very often emptying of food and barium through the pylorus could be seen to be unobstructed, and it was considered that some degree of gastric atony was playing a part in the observed retention. Unfortunately, it was possible to perform an insulin test on only 4 patients, because the remaining patients were unwilling to undergo the test. The response to insulin was positive in 1 patient, but negative in the other 3.
+
Progress of patients with recurrent ulceration (Table V ) Among the patients with recurrence, there were 6 who had continuous pain which failed to respond to medical treatment. In 3 a partial gastrectomy was carried out with good results. In the other 3, in accordance with the author’s personal preference at the present time, simple antrectomy with removal of part of the lesser curvature was performed with good results. Six patients have been treated conservatively so far because pain was not very severe except in one, and was adequately controlled in most cases by medical therapy. In 4 of these patients good results were quickly obtained with rapid disappearance of the ulcer crater, results which have been maintained continuously in 2 patients for more than 2 years. The other 2 patients have been advised to undergo operation because of persistence of the ulcer.
Discussion Early reports during the 1960s showed some good immediate results after the use of vagotomy and pyloroplasty for gastric ulcer (Dorton, 1963; Farris and Smith, 1963; Hendry and Bahrani, 1965; Burge, 1966; Kraft et al., 1966; Kennedy and George, 1967). However, the author’s findings were less impressive, with a recurrence rate of around 8 per cent (de Miguel, 1970). Stemmer et a]. (1968) were also dissatisfied and warned that in the long run gastric recurrence could be as high as 36 per cent. The early reports have now been considerably augmented, and more definitive evaluations are now available. Although some authorities still report very good results with only around 5 per cent of failures (Burge et al., 1970; Kraft et al., 1971; Lawson and Hutchison, 1973) or even less (Daniels and Strachan, 1973), others are clearly more pessimistic. For example, Duthie et al. (1970) reported a recurrence rate of 14.3 per cent, and Sawyers et al. (1971) a recurrence rate of 15 per cent. In the present study, in 64
which each patient has been followed up for more than 5 years, the recurrence rate was no less than 19 per cent. Recurrences appeared at intervals over the period of observation, that is, although recurrence took place in a few cases during the first 2 years, its incidence increased progressively with the passage of time and several recurrences were not seen until the fourth or fifth year. Two of the recurrences took 7 years to appear. Thus, it is clear that a shorter period of follow-up would have led to a fair proportion of the failures being missed. It is interesting to note that recurrence was much more common in women than in men (30 per cent against 16 per cent). In a previous publication (de Miguel, 1972) it was shown that only ‘primary’ gastric ulcers were affected by recurrence and that such a complication was not detected in any of the patients with ‘secondary’ gastric ulcer, that is, gastric ulceration associated with duodenal ulceration. It was considered on this basis that vagotomy might give a good chance of cure in the latter group of patients. Douglas and Duthie (1971), after a mean follow-up period of 3 years, came to a similar conclusion. However, the present assessment has shown that initial impression to be false, because patients with combined gastric and duodenal ulcers were clearly shown to be subject to recurrence of the gastric ulcer. It is interesting to note that not a single recurrence has been observed in the duodenum. This finding contrasts with the incidence of recurrence of 6.1 per cent found after the same operation in patients with duodenal ulcer alone (de Miguel, 1974), but admittedly the number of cases treated is insufficient to allow any firm conclusion. In each patient it was found radiologically that recurrence occurred in the same place as the ulcer had been located initially, even in the single case in which the ulcer crater had been completely excised. The possible role of gastric retention and associated hyperacidity in the aetiology of gastric ulcer was described long ago by Dragstedt (1953), and since then many other authorities have lent their support to this theory (Burge, 1966). It is certainly an attractive hypothesis but it cannot be regarded as completely proved. In the present study most of the patients with recurrent ulceration showed variable degrees of gastric retention, but in 4 patients no retention was observed after the ingestion of a food-barium meal. It could be claimed, of course, that the cause of recurrence in these 4 cases was gastric retention which was transient rather than persistent in nature. Such transient retention could perhaps also explain the long-lasting cure after medical treatment in some cases. On the other hand, it has been demonstrated that when a lesser curve gastric ulcer persists after vagotomy and pyloroplasty, the ulcer may heal after the addition of a gastro-enterostomy to drain the antrum more thoroughly (Burge et al., 1970). No particular differences were found between the Heineke-Mikulicz and the Finney pyloroplasty in the prevention of recurrence. When vagotomy with a drainage procedure is used in the surgical treatment of gastric ulcer, the role of the vagotomy as distinct from the drainage
877
Jacinto de Miguel procedure has not yet been firmly established. According to current knowledge of vagal function, however, it seems likely that vagotomy owes its therapeutic effect to the large reduction which it produces in the outputs of acid and pepsin as a result of the elimination of direct vagal release of gastrin, removal of the direct vagal ‘drive’ on the acid- and pepsin-secreting cells and diminution of the sensitivity of the parietal cells to circulating gastrin. On practical grounds as well the addition of vagotomy to the drainage procedure is supported by the finding that some failures after the use of pyloroplasty alone could be cured when vagal section was added (Kraft et al., 1971). However, in the present study it seems likely that recurrence of gastric ulceration was not due merely to incompleteness of the vagotomy, because in 3 cases out of the 4 in whom insulin tests were carried out the nerve section appeared to have been complete. In the group of patients with recurrent ulceration, there were 6 patients in whom reoperation had to be contemplated within a short time because of persistence of the ulcer crater. In all of them excisional surgery was performed in the form of a partial gastrectomy or, in accordance with the author’s present preference, simple antrectomy (with removal of only about 5 cm of distal greater curve but extending further up the lesser curvature), which seems to be a useful operation. Perhaps a simple gastro-enterostomy might have been equally effective, as indeed it has proved to be in the experience of Burge et al. (1970). Six other patients have been treated conservatively. Although 2 of them have been classified as failures because of persistence of the ulcer crater, 4 have achieved very good results which have been maintained for more than 2 years in 2 patients, an experience which indicates that it is well worth while trying medical treatment in cases of recurrence before resorting to reoperation. These results show that although vagotomy and pyloroplasty in the treatment of gastric ulcer can produce lasting cure of the disease in the majority of patients, there is a risk of recurrence in the long run, amounting to about 20 per cent. Because it has been found that addition of a gastro-enterostomy may lead to healing of a recurrent gastric ulcer and because of encouraging results in a small personal series of cases operated on primarily by vagotomy and gastroenterostomy for gastric ulcer, it is suggested that when conservative surgery for gastric ulcer is indicated, vagotomy with gastro-enterostomy might be followed by fewer recurrences than vagotomy and pyloroplasty. The possibilities offered by the modern technique of highly selective or proximal gastric vagotomy are beyond the scope of this article.
References BURGE H. (1966) The aetiology of benign lesser curve gastric ulcer; vagotomy and pyloroplasty in its treatment. Ann. R. Coll. Surg. Engl. 38, 349-369.
878
c. and STEDEFORD (1970) Four-year to eight-year results of vagotomy and simple drainage for benign lesser curve gastric ulcer. Br. Med. J . 3, 376-378. DANIELS H . A . and STRACHAN A . w. B. (1973) Gastric ulcer treated by vagotomy, pyloroplasty and ulcerectomy. Br. J. Surg. 60, 389-391. DORTON H. (1 963) In Discussion O f the paper O f FARRIS and SMITH (1963). DOUGLAS M. c. and DUTHIE H. L. (1971) Vagotomy for gastric ulcer combined with duodenal ulcer. Br. J. Surg. 58, 721-724. DRAGSTEDT L. R. (1953) Is gastric ulcer due to hyperfunction or dysfunction of the gastric antrum? Surg. Gynecol. Obstet. 97, 517-519. DUTHIE H. L., MOORE K. T. H., BARDSLEY D. and CLARK R. G. (1970) Surgical treatment of gastric ulcers. Controlled comparison of Billroth I gastrectomy and vagotomy and pyloroplasty. Br. J. Surg. 57, 784-787. FARRIS J. M. and SMITH G. K. (1963) Treatment of gastric ulcer (in situ) by vagotomy and pyloroplasty. Ann. Surg. 158, 461-472. HENDRY w. G. and BAHRANI A. L. (1965) Gastric ulcer and conservative surgery. Br. J. Surg. 52,588-596. KENNEDY T. and GEORGE J. D. (1967) Conservative surgery in the treatment of benign gastric ulcer. Gut 8, 632. KRAFT R. o., FRY w. J. and RANSON H. K . (1966) Vagotomy and pyloroplasty in the care of patients with gastric ulcer. Arch. Surg. 92, 456-462. KRAFT R. o., MYERS J., OVERTON s. and FRY w. J. (1971) Vagotomy and gastric ulcer. Am. J. Surg. 121, 122-1 26. LAWSON w . R . and HUTCHISON J. s. F. (1973) Vagotomy and pyloroplasty in the selective treatment of gastric ulcer. Br. J. Surg. 60, 713-716. DE MIGUEL J. (1968) Vagotomia asociada a1 drenaje del antro en el tratamiento de la ulcera gastrica. Rev. ESP.Enferm. Apar. Dig. 27, 3-21. DE MIGUEL J. (1970) Selective vagotomy and pyloroplasty in the treatment of gastric ulceration: some clinical observations and results. Br. J . Surg. 57, 3 38-343. DE MIGUEL J. (1972) Conservative surgical approach to the treatment of gastric ulcer. Br. J . Surg. Pract. 26,205-208. DE MIGUEL J. (1974) Late results of bilateral selective vagotomy and pyloroplasty for duodenal ulcer: 5-9-year follow-up. Br. J . Surg. 61, 264-269. SAWYERS J. L., SCOTT H. w. and GRAHAM c. (1971) Clinical trial of vagotomy and pyloroplasty in the treatment of benign gastric ulcer. Am. J. Surg. 121, 119421. STEMMER E. A., ZAHN R. L., HOM L. w. and CONNOLLY J. E. (1968) Vagotomy and drainage procedure for gastric ulcer. Arch. Surg. 96, 586-592. MURGEH., MORTON-HILL A., MACLEAN
R.
Recurrence of gastric ulcer after selective vagotomy and pyloroplasty for chronic uncomplicated gastric ulcer: a 5-10 year follow-up JACINTO DE M I G U E L * SUMMARY
Selective vagotomy and pyloroplasty were used in the surgical treatment of 73 patients with benign gastric ulcer between July 1964 and February 1970. Over the long period of observation recurrence of the gastric ulcer was found in 13 patients (191 per cent). This complication occurred equally commonly after treatment of primary and secondary gastric ulcers and was twice as frequent in women as in men. Possible reasons for these recurrences are discussed. It is concluded that vagotomy and pyloroplasty cure benign gastric ulcer in about 80 per cent of patients, and this should be taken into account in the choice of surgical treatment, especially in patients in whom a gastrectomy might put the patient’s life at risk. However, because of the high recurrence rate, it is doubtful whether this operation should be considered the treatment of choice for all cases of gastric ulcer. PARTIAL gastrectomy remains the favourite operation with most surgeons for the treatment of gastric ulcer, but in recent years vagotomy and pyloroplasty have been used as an alternative in several centres. Reports on the results after vagotomy and pyloroplasty are most conflicting. In particular, the recurrence rate has varied widely from centre to centre. This paper presents a review of observations on recurrent ulceration after vagotomy and pyloroplasty in the treatment of gastric ulcer. Patients and methods From July 1964 to February 1970, 73 patients with chronic uncomplicated gastric ulcer were operated upon personally by bilateral selective vagotomy and pyloroplasty. Patients having emergency operations, patients with ‘acute’ or ‘stress’ ulcer and those in whom the crater proved to be malignant were excluded from the study. In the course of the operation special care was taken to spare the hepatic and coeliac branches but to cut all the vagal branches passing to the stomach. The associated pyloroplasty was of Weinberg or Finney type and was performed in one layer with interrupted sutures. In most cases the gastric ulcer was biopsied by the four-quadrant technique and the pieces were submitted to immediate frozen section histological examination. It was also possible to carry out serial radiological observations during the postoperative period to follow the healing of the ulcer crater. It was found in nearly every case that the ulcer took about
2-3 weeks to disappear after the operation, no matter how big it had been originally. Later in the series the ulcers were excised completely from inside the stomach and the defect in the mucosa was closed with interrupted catgut sutures.
Follow-up studies The majority of the patients were followed up every 1 or 2 years. The interim results have been published previously (de Miguel, 1968, 1970, 1972). The latest of these assessments was carried out in the weeks prior to the preparation of this paper. Details of the followup are shown in Table I. Of the 3 unrelated deaths, one was due to a road accident 3&years after operation. Two other patients died 2 months and 1 month after the operation, from multiple emboli secondary to mitral stenosis and from probable coronary occlusion respectively. Three patients have been lost to follow-up. The remaining 67 patients (54 males and 13 females) were assessed as shown in Table II. Table I: STATE OF FOLLOW-UP 5-10 YEARS AFTER OPERATION 13 Total number of patients operated on Operative deaths 0 Late unrelated death 3 Lost to follow-up 3 Cases traced 5-10 years after operation 67 (96%) Table 11: METHOD OF ASSESSMENT ON FOLLOW-UP AT 5-10 YEARS Personal interview alone 19 Personal interview plus X-ray examination 32 Postal questionnaire 16
Fifty-one of the 67 patients attended for personal interview. Nineteen of them were found to be asymptomatic and no special investigation was considered necessary in these cases. The remaining 32 were submitted to radiological study, including all the patients in the series who had major or minor gastric symptoms. Some patients who had complained of symptoms related to the stomach and who were assessed by means of a postal questionnaire in the first instance were advised to come to the clinic for a personal interview and complementary radiological studies.
* Paseo De Zorrilla 30, Valladolid, Spain. 875
Jacinto de Miguel Ulcers were considered ‘primary’ when unassociated with duodenal ulcer, and ‘secondary’ when a duodenal deformity or an active duodenal ulcer was observed radiologically or at operation. Of the 67 traced cases, 45 had had ‘primary’ ulcers and 22 ‘secondary’ ulcers.
Recurrent gastric ulcer The recognition of this complication was generally easy. Most of the recurrences had been diagnosed at some time during the follow-up period but some of them were detected only at the latest assessment. Details of the recurrent ulcers according to the sex of the patient and the type of ulcer are shown in Table IIZ. The incidence of recurrence after operation for ‘secondary’ gastric ulcer was found to be the same as that after operation for ‘primary’ gastric ulcer. Recurrent ulceration was twice as frequent in women as in men. Tahle 111: RECURRENCE OF GASTRIC ULCER AFTER SELECTIVE VAGOTOMY AND PYLOROPLASTY FOR GASTRIC ULCER Recurrence No. of cases No. % Type of ulcer Male 35 6 17.1 Primary Female 10 3 30.0 3 15.8 Secondary I 33.3 13 19.1 Both types 67
Some aspects of recurrent ulceration Recurrences were analysed with respect to the time which had elapsed between the operation and the patient’s presentation with recurrence, the site of the recurrence, the type of pyloroplasty which had been performed, the degree of gastric retention, if any, and whether the ulcer had been left in situ or had been excised at the first operation (Table ZV). In 3 patients recurrence was diagnosed before 1 year had elapsed after the first operation. Indeed, none of the 3 patients was free of symptoms at any time and, though the ulcer crater was not detected radiologically for several months, it was suspected that in fact the ulcer had never healed. In 10 patients recurrence took place between 2 and 7 years after operation, with an average of 5 years. Again, in this regard, no differences were observed between primary and secondary gastric ulcers. In each case recurrence appeared in the same place as the original ulcer. Both types of pyloroplasty, Finney and Weinberg, were followed by this complication in similar proportions. In nearly all the patients with recurrent ulceration, the gastric ulcer has been left in situ at the first operation, but in 1 case it had been excised completely and the ulcer had reappeared in the same site. In order to study gastric emptying and detect any gastric retention a food-barium meal was given to the patient. Gastric retention was diagnosed empirically
Table IV: DETAILS OF PATIENTS WHO DEVELOPED RECURRENT ULCERATION Time interval before presentation Type of Ulcer excised Type of ulcer with recurrence Site of recurrence pyloroplasty or left in situ P S P P P S P S S P P P P
4.7 yr 5 4 yr 5.5 yr 10 mth 7.1 yf 3.0 yr 7 mth 4.4 yr 8 mth 4.6 yr 2.0 yr 6.9 yr 3.0 yr
Same (incisura) Same (lesser curve) Same (incisura) Same (incisura) Same (lesser curve) Same (incisura) Same (antrum) Same (incisura) Same (incisura) Same (lesser curve) Same (antrum) Same (lesser curve) Same (incisura)
w F
F W W F F
F F W F F F
Left Left Left Left Left Left Left Left Excised Left Left Left Left
Gastric retention
Hollander insulin test
+++
-
0 ?
++A
0
++
++t
t
+
-
++ ++ + 0
0
P, Primary ulcer; S, secondary ulcer; W, Weinberg pyloroplasty; F, Finney pyloroplasty. Table V: SYMPTOMATIC PROGRESS AND TREATMENT OF PATIENTS WITH RECURRENT GASTRIC ULCER Result a t latest Case Symptoms of recurrence Treatment of recurrence follow-up Observations Partial gastrectomy 1 Continuous pain Good Medica 1 Good 2 Mild pain No symptoms at >2$ yr Partial gastrectomy 3 Continuous pain Good 4 Continuous pain Partial gastrectomy Good 5 Mild pain Medical Good 6 Mild pain Medical Fair Crater still present 7 Continuous pain Antrectomy Good 8 Mild pain for 8 d Medical Good NO symptoms at > 2 yr 5, Persistent pain soon after the operation Antrectomy Good 10 Pain for 2 mth Medical Good 11 Continuous pain Antrectomy Good 12 Continuous pain for 3 mth Medical Fair Crater still present Medical Good 13 Mild pain
876
Gastric ulcer recurrence when barium was detected within the stomach after 6 hours. Different grades of retention were classified as follows: 0, N o barium seen at 6 hours. +, Barium evident at 7 hours. + +, Barium evident at 8 hours. + + +, Barium evident at more than 8 hours. When such a classification was used 3 patients showed marked gastric retention ( + +), 3 had a moderate degree of retention (+ +) and 2 had mild retention (+). In 4 patients no gastric retention (0) was found. One patient was not studied. It should be added that very often emptying of food and barium through the pylorus could be seen to be unobstructed, and it was considered that some degree of gastric atony was playing a part in the observed retention. Unfortunately, it was possible to perform an insulin test on only 4 patients, because the remaining patients were unwilling to undergo the test. The response to insulin was positive in 1 patient, but negative in the other 3.
+
Progress of patients with recurrent ulceration (Table V ) Among the patients with recurrence, there were 6 who had continuous pain which failed to respond to medical treatment. In 3 a partial gastrectomy was carried out with good results. In the other 3, in accordance with the author’s personal preference at the present time, simple antrectomy with removal of part of the lesser curvature was performed with good results. Six patients have been treated conservatively so far because pain was not very severe except in one, and was adequately controlled in most cases by medical therapy. In 4 of these patients good results were quickly obtained with rapid disappearance of the ulcer crater, results which have been maintained continuously in 2 patients for more than 2 years. The other 2 patients have been advised to undergo operation because of persistence of the ulcer.
Discussion Early reports during the 1960s showed some good immediate results after the use of vagotomy and pyloroplasty for gastric ulcer (Dorton, 1963; Farris and Smith, 1963; Hendry and Bahrani, 1965; Burge, 1966; Kraft et al., 1966; Kennedy and George, 1967). However, the author’s findings were less impressive, with a recurrence rate of around 8 per cent (de Miguel, 1970). Stemmer et a]. (1968) were also dissatisfied and warned that in the long run gastric recurrence could be as high as 36 per cent. The early reports have now been considerably augmented, and more definitive evaluations are now available. Although some authorities still report very good results with only around 5 per cent of failures (Burge et al., 1970; Kraft et al., 1971; Lawson and Hutchison, 1973) or even less (Daniels and Strachan, 1973), others are clearly more pessimistic. For example, Duthie et al. (1970) reported a recurrence rate of 14.3 per cent, and Sawyers et al. (1971) a recurrence rate of 15 per cent. In the present study, in 64
which each patient has been followed up for more than 5 years, the recurrence rate was no less than 19 per cent. Recurrences appeared at intervals over the period of observation, that is, although recurrence took place in a few cases during the first 2 years, its incidence increased progressively with the passage of time and several recurrences were not seen until the fourth or fifth year. Two of the recurrences took 7 years to appear. Thus, it is clear that a shorter period of follow-up would have led to a fair proportion of the failures being missed. It is interesting to note that recurrence was much more common in women than in men (30 per cent against 16 per cent). In a previous publication (de Miguel, 1972) it was shown that only ‘primary’ gastric ulcers were affected by recurrence and that such a complication was not detected in any of the patients with ‘secondary’ gastric ulcer, that is, gastric ulceration associated with duodenal ulceration. It was considered on this basis that vagotomy might give a good chance of cure in the latter group of patients. Douglas and Duthie (1971), after a mean follow-up period of 3 years, came to a similar conclusion. However, the present assessment has shown that initial impression to be false, because patients with combined gastric and duodenal ulcers were clearly shown to be subject to recurrence of the gastric ulcer. It is interesting to note that not a single recurrence has been observed in the duodenum. This finding contrasts with the incidence of recurrence of 6.1 per cent found after the same operation in patients with duodenal ulcer alone (de Miguel, 1974), but admittedly the number of cases treated is insufficient to allow any firm conclusion. In each patient it was found radiologically that recurrence occurred in the same place as the ulcer had been located initially, even in the single case in which the ulcer crater had been completely excised. The possible role of gastric retention and associated hyperacidity in the aetiology of gastric ulcer was described long ago by Dragstedt (1953), and since then many other authorities have lent their support to this theory (Burge, 1966). It is certainly an attractive hypothesis but it cannot be regarded as completely proved. In the present study most of the patients with recurrent ulceration showed variable degrees of gastric retention, but in 4 patients no retention was observed after the ingestion of a food-barium meal. It could be claimed, of course, that the cause of recurrence in these 4 cases was gastric retention which was transient rather than persistent in nature. Such transient retention could perhaps also explain the long-lasting cure after medical treatment in some cases. On the other hand, it has been demonstrated that when a lesser curve gastric ulcer persists after vagotomy and pyloroplasty, the ulcer may heal after the addition of a gastro-enterostomy to drain the antrum more thoroughly (Burge et al., 1970). No particular differences were found between the Heineke-Mikulicz and the Finney pyloroplasty in the prevention of recurrence. When vagotomy with a drainage procedure is used in the surgical treatment of gastric ulcer, the role of the vagotomy as distinct from the drainage
877
Jacinto de Miguel procedure has not yet been firmly established. According to current knowledge of vagal function, however, it seems likely that vagotomy owes its therapeutic effect to the large reduction which it produces in the outputs of acid and pepsin as a result of the elimination of direct vagal release of gastrin, removal of the direct vagal ‘drive’ on the acid- and pepsin-secreting cells and diminution of the sensitivity of the parietal cells to circulating gastrin. On practical grounds as well the addition of vagotomy to the drainage procedure is supported by the finding that some failures after the use of pyloroplasty alone could be cured when vagal section was added (Kraft et al., 1971). However, in the present study it seems likely that recurrence of gastric ulceration was not due merely to incompleteness of the vagotomy, because in 3 cases out of the 4 in whom insulin tests were carried out the nerve section appeared to have been complete. In the group of patients with recurrent ulceration, there were 6 patients in whom reoperation had to be contemplated within a short time because of persistence of the ulcer crater. In all of them excisional surgery was performed in the form of a partial gastrectomy or, in accordance with the author’s present preference, simple antrectomy (with removal of only about 5 cm of distal greater curve but extending further up the lesser curvature), which seems to be a useful operation. Perhaps a simple gastro-enterostomy might have been equally effective, as indeed it has proved to be in the experience of Burge et al. (1970). Six other patients have been treated conservatively. Although 2 of them have been classified as failures because of persistence of the ulcer crater, 4 have achieved very good results which have been maintained for more than 2 years in 2 patients, an experience which indicates that it is well worth while trying medical treatment in cases of recurrence before resorting to reoperation. These results show that although vagotomy and pyloroplasty in the treatment of gastric ulcer can produce lasting cure of the disease in the majority of patients, there is a risk of recurrence in the long run, amounting to about 20 per cent. Because it has been found that addition of a gastro-enterostomy may lead to healing of a recurrent gastric ulcer and because of encouraging results in a small personal series of cases operated on primarily by vagotomy and gastroenterostomy for gastric ulcer, it is suggested that when conservative surgery for gastric ulcer is indicated, vagotomy with gastro-enterostomy might be followed by fewer recurrences than vagotomy and pyloroplasty. The possibilities offered by the modern technique of highly selective or proximal gastric vagotomy are beyond the scope of this article.
References BURGE H. (1966) The aetiology of benign lesser curve gastric ulcer; vagotomy and pyloroplasty in its treatment. Ann. R. Coll. Surg. Engl. 38, 349-369.
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c. and STEDEFORD (1970) Four-year to eight-year results of vagotomy and simple drainage for benign lesser curve gastric ulcer. Br. Med. J . 3, 376-378. DANIELS H . A . and STRACHAN A . w. B. (1973) Gastric ulcer treated by vagotomy, pyloroplasty and ulcerectomy. Br. J. Surg. 60, 389-391. DORTON H. (1 963) In Discussion O f the paper O f FARRIS and SMITH (1963). DOUGLAS M. c. and DUTHIE H. L. (1971) Vagotomy for gastric ulcer combined with duodenal ulcer. Br. J. Surg. 58, 721-724. DRAGSTEDT L. R. (1953) Is gastric ulcer due to hyperfunction or dysfunction of the gastric antrum? Surg. Gynecol. Obstet. 97, 517-519. DUTHIE H. L., MOORE K. T. H., BARDSLEY D. and CLARK R. G. (1970) Surgical treatment of gastric ulcers. Controlled comparison of Billroth I gastrectomy and vagotomy and pyloroplasty. Br. J. Surg. 57, 784-787. FARRIS J. M. and SMITH G. K. (1963) Treatment of gastric ulcer (in situ) by vagotomy and pyloroplasty. Ann. Surg. 158, 461-472. HENDRY w. G. and BAHRANI A. L. (1965) Gastric ulcer and conservative surgery. Br. J. Surg. 52,588-596. KENNEDY T. and GEORGE J. D. (1967) Conservative surgery in the treatment of benign gastric ulcer. Gut 8, 632. KRAFT R. o., FRY w. J. and RANSON H. K . (1966) Vagotomy and pyloroplasty in the care of patients with gastric ulcer. Arch. Surg. 92, 456-462. KRAFT R. o., MYERS J., OVERTON s. and FRY w. J. (1971) Vagotomy and gastric ulcer. Am. J. Surg. 121, 122-1 26. LAWSON w . R . and HUTCHISON J. s. F. (1973) Vagotomy and pyloroplasty in the selective treatment of gastric ulcer. Br. J. Surg. 60, 713-716. DE MIGUEL J. (1968) Vagotomia asociada a1 drenaje del antro en el tratamiento de la ulcera gastrica. Rev. ESP.Enferm. Apar. Dig. 27, 3-21. DE MIGUEL J. (1970) Selective vagotomy and pyloroplasty in the treatment of gastric ulceration: some clinical observations and results. Br. J . Surg. 57, 3 38-343. DE MIGUEL J. (1972) Conservative surgical approach to the treatment of gastric ulcer. Br. J . Surg. Pract. 26,205-208. DE MIGUEL J. (1974) Late results of bilateral selective vagotomy and pyloroplasty for duodenal ulcer: 5-9-year follow-up. Br. J . Surg. 61, 264-269. SAWYERS J. L., SCOTT H. w. and GRAHAM c. (1971) Clinical trial of vagotomy and pyloroplasty in the treatment of benign gastric ulcer. Am. J. Surg. 121, 119421. STEMMER E. A., ZAHN R. L., HOM L. w. and CONNOLLY J. E. (1968) Vagotomy and drainage procedure for gastric ulcer. Arch. Surg. 96, 586-592. MURGEH., MORTON-HILL A., MACLEAN
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