World J. Surg. I, 9-17, 1977

Review of Elective Surgical Treatment of Chronic Duodenal Ulcer STEPHEN D . FELDMAN,

M.D.,

LESLIE WISE,

M.D., and WALTER

F. BALLINGER, M . D .

Department of Surgery, Washington University, School of Medicine, St. Louis, Missouri, U.S.A.

This article is a review of 20 clinical trials of various forms of elective surgical treatment of chronic duodenal ulcer conducted between 1964 and 1975, some of them prospective and others retrospective in nature. Comparisons have been made of the results following truncal vagotomy with drainage, truncal vagotomy with antrectomy, and partial gastrectomy. Additionally, selective vagotomy and truncal vagotomy have been compared in some studies and various forms of drainage, such as pyloroplasty and gastrojejunostomy, have been compared in others. In general, the results of all current forms of elective surgery for chronic duodenal ulcer have been very good, and the differences among the effects of the various procedures have been small. There have been no significant differences in the mortality rates associated with the several operations when they have been performed electively. The rate of ulcer recurrence and incidence of diarrhea have been somewhat higher after truncal vagotomy with drainage, whereas the frequency of dumping and amount of weight loss have been somewhat greater after all forms of gastric resection. Selective vagotomy appears to be associated with less frequent and severe diarrhea than does truncal vagotomy. There have been no apparent differences in the results of the various drainage procedures that have been combined with vagotomy. Highly selective vagotomy without drainage, the most recent operation for duodenal ulcer, has resulted in the lowest incidence of post-operative side effects of any surgical procedure in current use. However, the frequency of ulcer recurrence after this therapeutic measure remains to be determined by long-term studies.

Duodenal ulcer disease was described as a distinct pathologic entity in the latter half of the 19th century. By 1904, following the work of Billroth and others, the Mayos had operated on 58 cases of duodenal ulcer. Latarjet first employed vagal section for the treatment of duodenal ulcer disease in 1922. Nonetheless, the extent of vagotomy, the type of drainage procedure, or even the very necessity of drainage has not yet been defined over a half-century later.

Reprint requests to."Walter F. Ballinger, M.D., Department of Surgery, 4960 Audubon, St. Louis, Missouri 63110, U.S.A.

Part of the difficulty in arriving at clear conclusions regarding the surgical treatment of duodenal ulcer has been due to wide variations in the methods used to conduct clinical trials and in the criteria used to evaluate the results. Selection of patients for study and the indications for operation need to be more clearly defined. Age is an important factor. Blumenthal [1 ] has shown that death rates from peptic ulcer per 100,000 men are low in those under 30 years of age, increase after age 60, and reach a rate of 80 per 100,000 at age 80. Emergency operations clearly carry higher risks, regardless of the specific procedure used. Studies that are designed to be randomly controlled frequently are not, since the operating surgeon may feel that the patient is "too sick" for the randomly selected procedure or because he feels that technical problems preclude a specific procedure. A further difficulty in obtaining conclusive information about the results o f surgical therapy is the lack of standardization of surgical procedures, Frequently, the thoroughness of vagotomy or the amount of resected stomach is difficult to ascertain. In addition, it is often difficult to make comparisons in the follow-up assessment. The most objective studies are those in which the follow-up team is different from the operating team and is not aware of the type of operation that was performed. Difficulties in defining terms such as dumping and diarrhea have also made for problems in comparing studies performed in different centers. Recognizing the obvious limitations in making comparisons and the shortcomings of many studies, we will review 20 trials that addressed themselves to the treatment of chronic duodenal ulcer disease. Results

lllingworth and Cox." Glasgow I (1958 and 1968) In this trial comparisons were made of partial gastrectomy with gastroenterostomy (Billroth II type

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gastrectomy), truncal vagotomy with gastrojejunostomy, and gastroenterostomy alone [2, 3]. The study was started in 1958 and had an 83% follow-up rate. Members of the vagotomy and gastrectomy groups were similar in age, height, weight, and the time since operation. Early in the study an unacceptably high number of recurrent marginal ulcers appeared in patients with gastroenterostomy alone, and this portion of the trial was terminated. Final data revealed essentially no differences in postoperative alimentary symptoms, except for the more frequent occurrence of a postcibal sensation of fullness in the partial gastrectomy group (p < 0.00l). Recurrent ulceration was less frequent after gastrectomy than after vagotomy and gastroenterostomy.

Leeds-York Trial (1964 and 1968) Goligher and associates [4, 5] compared (a) truncal vagotomy with posterior dependent gastrojejunostomy, (b) truncal vagotomy with antrectomy, and (c) two-thirds to three-fourths distal partial gastrectomy with gastrojejunostomy. This study included 634 patients--507 men and 127 women. The nine participating surgeons were permitted to exclude patients from the trial at their discretion, and, consequently, their personal opinions had effects on randomization (i.e., some thin patients did not undergo gastrectomies, and patients with a recent history of hemorrhage underwent partial gastrectomy). One hundred thirty-two men (26%) were rejected from the trial and most of them received vagotomy and gastroenterostomy. These patients were also followed and the results were quite similar to those of the vagotomy with gastroenterostomy group within the trial. The results were assessed by a group of clinicians unaware of the specific type of operation employed. From 1963 to 1965 a second Leeds-York study was undertaken in which 192 men with chronic duodenal ulcer disease received truncal vagotomy and HeinekeMikulicz pyloroplasty [6]. The 5- to 8-year follow-up results from this group were compared to those of the original group. The difficulty with this type of nonconcurrent comparison is obvious, although patients were from the same population base, and the methods of study were similar. The only death in the entire series was due to postoperative pulmonary complicatons in the vagotomy-pyloroplasty group. Diarrhea was least frequent after gastrectomy, but weight loss was most severe after gastric resection, whether done as the classic subtotal resection or as an antrectomy with vagotomy. Recurrent ulcers were less frequent after resectional procedures than after vagotomy with simple drainage. Of 164 patients who had vagotomy with pyloroplasty, 11 had proven recurrences at lap-

World J. Surg. Vol. i, No. 1, January 1977

arotomy and an additional 7 were highly suspected of having recurrent ulcers. In 119 cases of vagotomy with gastroenterostomy, 3 recurrences were proven by re-exploration and 4 were highly suspected. In 116 cases of vagotomy with antrectomy, no recurrences were demonstrable by laparotomy and only 2 were highly suspected. Of 107 patients with subtotal gastrectomy, 1 had a recurrent ulcer proven by lapatotomy, and 1 was highly suspected of having a recurrence. A modified Visick grading system was used for judging the results. By this method of evaluation, more patients were displeased after vagotomy and pyloroplasty (18%) than after vagotomy-gastroenterostomy (11%), vagotomy-antrectomy (8%), and partial gastrectomy (6%). Of the 127 women eligible for the Leeds-York study, 50 were rejected because the surgeons were fearful of the results of partial gastrectomy in women and elected to do vagotomy with gastroenterostomy. The number that remained was insufficient to permit significant comparisons of the groups. Nevertheless, comparisons could be made between men and women who had vagotomy with gastroenterostomy if patients within the trial and those excluded (who received vagotomy with gastroenterostomy) were considered. From this pooled data, bilious vomiting, nausea, and epigastric fullness were significantly greater postoperatively in women than in men (p < 0.001). Postoperative evaluation placed 22% of the women in Visick category IV, whereas the Corresponding percentage for men was 14%. Visick categories I and II contained 71% of the male sample and only 58% of the female group [7].

Kennedy, Kay, et al.; Glasgow H (1973) Between 1965 and 1971 a controlled trial was conducted in 547 patients comparing truncal vagotomy with gastrojejunostomy to truncal vagotomy with Heineke-Mikulicz pyloroplasty [8]. All patients had duodenal ulcers and no emergency cases were included. When the diagnosis was not clear at laparotomy, a pyloroplasty was made to confirm the presence of a duodenal ulcer and a vagotomy was added. This constituted a third group. A fourth group arose from patients in whom a pyloroplasty was judged unsafe. This group received gastrojejunostomies with truncal vagotomies. Groups 1 and 2 were well matched for sex, age, weight, and symptoms. The overall mortality for the four groups was 0.5%. For the trial groups 1 and 2 consisting of 404 patients mortality was 0.25%. Eighty-two percent of groups 1 and 2 were followed for a minimum of 2 years. Of the 166 patients who had random vagotomy and pyloroplasty, 4.8% had proven recurrent ulcers and 27% had dumping symptoms. Of the 165 patients

S. D. Feldman et al: Elective Surgery of Duodenal Ulcer

who underwent random vagotomy and gastrojejunostomy, 3.0% had proven recurrent ulcers and 16% experienced dumping symptoms. A total of 16% of those with gastroenterostomy had bilious vomiting whereas only 6% without gastroenterostomy had this complication. The incidence of diarrhea was the same for both groups, 1.1%. The final evaluation indicated that the Visick grades for all four groups differed little, each group having greater than 90% in the good rating categories (Visick I and II). This study indicated that good results were obtained from either vagotomy with pyloroplasty or vagotomy with gastrojejunostomy.

Veterans Admin&tration Cooperative Trial (1970 and 1973) Postlethwait, Price, and colleagues [9, 10] reported 2and 5-year follow-up results of a study involving 1357 male veterans in 17 hospitals. Four operations were compared, namely, truncal vagotomy and drainage (337 patients), truncal vag0tomy and antrectomy (331 patients), truncal vagotomy and hemigastrectomy (343 patients) and gastric resection (346 patients). The type of drainage used was a matter of the surgeon's choice. Antrectomy was defined as removal of 20 to 30% of the distal stomach, hemigastrectomy involved resection of 50% of the distal stomach, and gastrectomy without vagotomy involved a distal two-thirds to three-fourths resection. A 5-year follow-up rate of 84.7% of the patients was achieved. Patients with previous operations that might have affected the gastric response were excluded except for those who had simple oversewing of a previous ulcer perforation. Emergency cases were "almost totally" excluded. Operative mortality ranged from 0.6% for vagotomy and pyloroplasty to 1.8% for gastric resection, not a statistically significant difference with this number of patients. The ulcer recurrence rate for vagotomy and pyloroplasty of 8.9% was significantly higher than the rate of 0.8% for vagotomy and antrectomy. All other parameters that were measured gave essentially similar results regardless of the type of operation. However, there appeared to be a direct relationship between the amount of stomach removed and the need for ulcer medication, the occurrence of early satiety, and the finding of a hemoglobin of less than 10 g/!00 ml. These results suggested that vagotomy with partial gastric resection was the better procedure, having a low mortality rate and the lowest ulcer rate.

Veterans Administration Study, Minnesota (1973) Howard, Murphy, and Humphrey [11] published the results of a comparison among vagotomy and Hein-

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eke-Mikulicz pyloroplasty, vagotomy and hemigastrectomy, and subtotal gastrectomy with Billroth II gastroenterostomy. Of 267 original patients, 201 were followed for at least 2 years. Operations for obstruction were included, but all cases were considered elective. Patients with previous ulcer operations were excluded except those who had undergone simple oversewing of an ulcer perforation. There were no deaths in this series. Dumping was defined as any degree of sweating or weakness after meals. Of those with vagotomy and pyloroplasty, 8.5% had dumping, whereas 27% of patients with either vagotomy and hemigastrectomy or subtotal gastrectomy experienced this complication. No other postoperative symptoms were significantly different among the groups. Ulcer recurrence rates were not statistically different among the three groups, although the recurrence rate after vagotomy and pyloroplasty was 10%, whereas it was only 4% after vagotomy and hemigastrectomy and 5% after 75% subtotal gastrectomy.

Veterans A dministration Study of Jordan and Condon (1970 and 1974) Jordan and Condon [12, 13] randomized 200 male veteran patients between truncal vagotomy with drainage and truncal vagotomy with antrectomy. Although operations were called elective, the indications for operation included bleeding, obstruction, and perforation. In 16 patients the ulcer was in the prepyloric area, at the pylorus, or just proximal to the pylorus. The drainage procedure was a HeinekeMikulicz pyloroplasty, although a gastroenterostomy could be substituted at the surgeon's discretion. Similarly, a Billroth II reconstruction could be substituted for a Billroth I procedure if duodenal scarring dictated so doing. By the original random selection method, these investigations assigned 98 patients to vagotomy and pyloroplasty and placed 102 in the truncal vagotomy with antrectomy group. Because of breaks in the protocol, the following operations were actually done: vagotomy and pyloroplasty in 94 patients, vagotomy and gastroenterostomy in 14 patients, vagotomy and Billroth I gastrectomy in 73 patients, and vagotomy and Billroth II gastrectomy in 19 patients. Ninety-four percent of the patients were followed for from 5 to 8 years after their operations or until their deaths. Operative mortality for vagotomy and drainage was 2%, and there were no deaths follt~wing vagotomy and antrectomy. Postoperative stomal dysfunction and reoperation were greater after vagotomy and drainage than after the other procedure. Gastrointestinal complaints during the study were not statistically different for the two groups. Recurrent ulcer developed in 9 of 108 patients after vagotomy and drain-

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age and in only 1 of 92 patients after vagotomy and antrectomy. The patients' own assessments of the clinical results were nearly identical. The authors pointed out that 10 patients who should have had antrectomies had drainage procedures instead because of duodenal scarring. Allowing for some degree of patient selection, Jordan and Condon concluded that vagotomy and antrectomy was the better procedure since there were fewer recurrent ulcers while morbidity and mortality rates were similar to those of vagotomy and drainage. These findings were similar to those of Sawyers and associates in a nonrandomized study.

Thompson and Read (1975) In the study of Thompson and Read [15], 200 patients had either a truncal vagotomy with Heineke-Mikulicz pyloroplasty or a truncal vagotomy with Finney pyloroplasty. Patients were followed for a mean of 5.2 years. There was 1 immediate postoperative death, 16 patients died of causes unrelated to surgery in the follow-up period, and 9 other patients were lost to follow-up. Of the remaining patients, 90 had Heineke-Mikulicz pyloroplasties and 84 had Finney pyloroplasties. Considering proven, probable, and possible recurrences, it was found that both groups had a 13% recurrence rate. The incidence of positive Hollander tests at follow-up was 53% for Finney pyloroplasty and 47% for Heineke-Mikulicz pyloroplasty, obviously not statistically significantly different. The frequency of delayed gastric emptying was 26% and 20%, respectively, for the Finney and the HeinekeMikulicz pyloroplasty groups--again quite similar. Patients with a Finney pyloroplasty had dumping and diarrhea rates of 10.7% and 2.4%, whereas patients with the Heineke-Mikulicz pyloroplasty had rates of 14.4% and 2.2%. The authors concluded that the two types of pyloroplasty gave an equally good result.

Truncal Vagotomy Versus Selective Vagotomy (19671973) As studies attempted to show which drainage procedure was most efficacious, the controversy between truncal and selective vagotomy mushroomed. Denervation of the small bowel and biliary tree had been incriminated as a factor in accentuating diarrhea and causing cholelithiasis after truncal vagotomy. Several studies were initiated to test selective vagotomy, including those of Kraft and associates (1967), Mason and associates (1968), Sawyers and associates (1968), T. Kennedy and Connell (1973), and Kronborg and associates (1970). Kraft et al [16] studied 100 male veterans. The Finney

World J. Surg. Vol. 1, No. 1, January 1977

pyloroplasty was used in 95 cases, a Jaboulay gastroduodenostomy in 4, and a gastrojejunostomy in 1 case. Selective vagotomy was compared to truncal vagotomy in an alternating pattern, although this was abandoned in cases of massive hemorrhage. Additionally, the operations were not confined to chronic duodenal ulcers. With these limitations in the study and only a 4-year follow-up, the authors found no significant differences between the two vagotomy procedures except in the area of patient satisfaction: slightly more patients with selective vagotomy believed they were doing well than patients with truncal vagotomy. Mason and colleagues [17], comparing selective with truncal vagotomy, had early difficulties obtaining complete selective vagotomies. With time, incompleteness of selective vagotomy diminished. Nonetheless, it still ran 50% higher than the incompleteness rate recorded with truncal vagotomy. Even at this rate of incompleteness, the incidence of diarrhea was less with selective vagotomy. Follow-up in this trial was for only 3 months, and the drainage procedures were not uniform. Sawyers and associates [18] reported the results of 145 patients in whom selective vagotomy and truncal vagatomy were compared. Drainage procedures included pyloroplasty, antrectomy, and gastrojejunostomy, Indications for operation varied, only 67% of the operations being performed for duodenal ulcer. Randomization was skewed because of technical difficulties or patient status, such that truncal vagotomy was performed in 63% of the patients and selective vagotomy in 37%. Results 0fthis study were: (a) the incidence of diarrhea with truncal vagotomy was 21%, whereas the incidence with selective vagotomy was only 12%; (b) positive Hollander tests postoperatively occurred in 19% of patients after truncal vagotomy but in only 2% of patients after selective vagotomy; (c) there was one recurrent ulcer in the truncal vagotomy group and none in the selective vagotomy group. From the point of view of the patients there was no difference in the clinical results between truncal and selective vagotomy. Kennedy, Connell, and associates [19, 20] compared results of truncal vagotomy and selective vagotomy with those of pyloroplasty after 5 years. The two groups were well matched. There were no deaths in either group and there was no significant difference in postoperative complications. Results included a higher incidence of recurrent ulcers, a higher incidence of diarrhea, and a higher incidence of incomplete vagotomies in the truncal vagotomy group. In terms of clinical grading, there was no significant difference between the groups. The Kronborg, Malstrome, and Christiansen [21] series of 81 patients from Denmark was a random-

S. D. Feldman et al: Elective Surgery of Duodenal Ulcer

ized, controlled comparison of truncal vagotomy and selective vagotomy. Heineke-Mikulicz pyloroplasty was the drainage procedure in 72 patients, but 4 patients with selective vagotomy and 5 patients with truncal vagotomy had gastrojejunostomies because of excessive pyloric scarring. Five-year follow-up involved 76 patients (94%). No difference was apparent in the recurrent ulcer rate. Diarrhea was more frequent after truncal vagotomy than after selective vagotomy. Histamine- and insulin-activated gastric acid secretion was the same 10 days postoperatively in the two groups, but after 5 years the insulin-activated response was greater in the selective group. Johnston [22] reviewed the pooled data of 13 trials comparing truncal and selective vagotomy. Of 790 patients, 12.3% experienced diarrhea when their operation consisted of selective vagotomy with a drainage procedure, whereas 24.6% of 1130 patients reported diarrhea when truncal vagotomy with a drainage procedure was employed. The diarrhea with selective vagotomy was usually mild, but in 2% of the cases it was severe enough to render the operation a failure. Burge et al [23] have suggested that in the absence of organic pyloric stenosis, selective vagotomy without drainage is adequate. However, others have indicated that selective vagotomy without drainage predisposes to gastric stasis and ulcers [24]. Sawyers and Scott [25] and T. Kennedy and associates [26] have examined the results of different drainage procedures used with selective vagotomy. In the Sawyers and Scott study, 57 men and 22 women were randomly divided. The results of selective vagotomy with pyloroplasty (Finney or Jaboulay) and selective vagotomy with antrectomy (Billroth I and Billroth II) were compared. Average follow-up was 30 months. One patient had a recurrent ulcer, and this followed a selective vagotomy and Billroth I antrectomy. There were no operative deaths and no significant differences in the incidence of dumping and diarrhea. Patient appraisal of the clinical results was nearly identical for the two groups. This study showed no advantage for antrectomy with selective vagotomy over pyloroplasty with selective vagotomy. T. Kennedy, Connell, and associates, in a randomized, controlled study compared gastrojejunostomy to Finney pyloroplasty when each was combined with a selective vagotomy. Mean follow-up was 3.5 years, and the follow-up rate was 97%. Two proven recurrences were reported after pyloroplasty and one after gastrojejunostomy. The Visick grading was marginally better for gastrojejunostomy, and there was slightly less dumping, less increase in bowel frequency, and less flatulence after gastrojejunostomy. These differences, however, were not statistically significant, nor was the slightly lower incidence of bilious vomiting observed after pyloroplasty.

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Highly Selective Vagotomy (Parietal Vagotomy) Without Drainage (1970-1975) The occurrence of dumping as a side effect of both truncal vagotomy and selective vagotomy stimulated the development of highly selective vagotomy. Dumping seems to be due in large part to the loss of pyloric control of gastric emptying. The concept of highly selective vagotomy without drainage was introduced simultaneously by Amdrup and Jensen [27] in Copenhagen and by Johnston and Wilkinson in Leeds [28]. Amdrup, Johnston, and colleagues [29] reviewed the combined data of 271 patients treated electively for duodenal ulcer in Leeds and Copenhagen by highly selective vagotomy; 108 of these patients were followed for 2 to 4 years. Gastric stasis necessitated reoperation in 2 patients. Gastric ulcer developed twice, and 3 cases of recurrent duodenal ulcer were suspected but not confirmed at reoperation. There were no operative deaths. Results included a total incidence of dumping of 5.6%, mild diarrhea in 4%, and moderate diarrhea in 1% of patients. The overall Visick grading placed 88% of patients in categories I and II. Uncontrolled comparisons with truncal vagotomy and selective vagotomy with drainage in Leeds and Copenhagen showed a much reduced incidence of dumping, bilious vomiting, and diarrhea after highly selective vagotomy, without an increase in gastric stasis. Goligher [30] reviewed the results of 250 patients who were electively treated at Leeds for chronic duodenal ulcer with highly selective vagotomy and no drainage. The operative mortality was nil. Fifty-eight patients were followed for at least 2 years, and these patients were compared to patients in the earlier Leeds-York trial who were followed for a similar length of time. Again, diarrhea and dumping were less in the group with highly selective vagotomy without drainage. However, with regard to recurrent alceration and Visick grading, partial gastrectomy with or without vagotomy seemed to be somewhat better. Kronborg and Madsen [31] entered 100 patients in a randomized, controlled trial of highly selective vagotomy without drainage and selective vagotomy with pyloroplasty. One-year follow-up was 96%. Operative mortality was zero. Dumping, diarrhea, and epigastric fullness were significantly lower after highly selective vagotomy (6%, 6%, and 8%, respectively) than after selective vagotomy (30%, 20%, and 28%, respectively). Recurrent or persistent ulcers were observed in 11 patients who had highly selective vagotomy, whereas only 4 with selective vagotomy and pyloroplasty had recurrences. Visick classifications were similar. Wastell and associates [32] conducted a small pros-

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pective trial o f highly selective v a g o t o m y w i t h o u t d r a i n a g e . O f 16 p a t i e n t s receiving t h e o p e r a t i o n , 2 h a d p r o v e n recurrences within 3 to 12 m o n t h s . Clearly, no single o p e r a t i o n is best for all situations. F r o m the trials reviewed above, it can be conc l u d e d t h a t p a r t i a l g a s t r e c t o m y with or w i t h o u t vag o t o m y can be carried o u t with a l m o s t the s a m e m o r t a l i t y r a t e as simple d r a i n a g e if s o m e degree o f selection is exercised. Similarly, gastric resection, with or w i t h o u t v a g o t o m y , p r o v i d e s a lower ulcer r e c u r r e n c e rate than v a g o t o m y with d r a i n a g e . In t e r m s o f p a t i e n t satisfaction, v a g o t o m y a n d d r a i n a g e a n d the gastric resection p r o c e d u r e s a p p e a r to p r o vide similar results. Selective v a g o t o m y a n d h i g h l y selective v a g o t o m y represent t h e o r e t i c a l i m p r o v e m e n t s over p r e v i o u s l y used o p e r a t i v e p r o c e d u r e s , b u t the i n d i c a t i o n s for these m o d i f i c a t i o n s a n d their longt e r m results are yet to be d e t e r m i n e d . R6sum6

C e t article passe en revue 20 6tudes cliniques c o m pil6es entre 1964 et 1975 sur le t r a i t e m e n t chirurgical 61ectif des ulc~res d u o d 6 n a u x c h r o n i q u e s : certaines de ces ~tudes sont de n a t u r e prospectives, d ' a u t r e s r~trospectives. O n y c o m p a r e les r6sultats o b t e n u s p a r v a g u o t o m i e t r o n c u l a i r e avec d r a i n a g e , v a g u o t o m i e t r o n c u l a i r e et a n t r e c t o m i e , et g a s t r e c t o m i e partielle. De plus. d a n s certalnes ~tudes. on a c o m p a r ~ la v a g u o t o m i e s~lective et la v a g u o t o m i e t r o n c u l a i r e t a n d i s que d ' a u t r e s 6tudes c o m p a r a i e n t diff6rentes formes de d r a i n a g e , p a r e x e m p l e p y l o r o p l a s t i e et gast r o - j 6 j u n o s t o m i e . En g6n6ral les r6sultats o b t e n u s ont 6t6 tr6s b o n s et il n'y a p a s eu de diff6rence slgnificative entre les diverses f o r m e s de t r a i t e m e n t chirurgical 61ectif p o u r ulc6re d u o d 6 n a l c h r o n i q u e . Les taux de m o r t a l i t 6 o n t 6t6 sensiblement identiques p o u r t o u t e s les p r o c 6 d u r e s c h i r u r g i c a l e s l o r s q u e p r a tiqu6es 61ectivement. L a r6cidive d'ulcbre et la diarrh6e p o s t - o p 6 r a t o i r e se sont rencontr6es plus souvent apr6s v a g u o t o m i e t r o n c u l a i r e et d r a i n a g e , t a n d i s que l ' i n c i d e n c e du s y n d r 6 m e de chasse g a s t r i q u e ( " d u m p i n g " ) , et la p e r t e de p o i d s o n t 6t6 plus souvent associ6s avec toutes les formes de r6section gastrique. La v a g u o t o m i e s61ective s e m b l e s ' a c c o m p a g n e r m o i n s s o u v e n t de d i a r r h 6 e p o s t - o p 6 r a t o i r e grave que la v a g u o t o m i e t r o n c u l a i r e . Les diff6rentes p r o c 6 d u r e s de d r a i n a g e employ6es en m~me t e m p s que la v a g u o t o m i e n ' o n t pas d e t e r m i n 6 de diff6rence significative. L a v a g u o t o m i e supra-s61ective sans d r a i n a g e , la derni6re n o u v e a u t 6 darts le t r a i t e m e n t chirurgical des ulc~res d u o d 6 n a u x , s'est a c c o m p a g n 6 e du plus faible t a u x d'effets s e c o n d a i r e s p o s t - o p 6 r a t o i r e s l o r s q u e c o m p a r 6 e h t o u t e s les autres formes de t r a i t e m e n t chirurgical c o u r a m m e n t employ6s. I1 f a u d r a cepend a n t a t t e n d r e les r6sultats d ' 6 t u d e h long t e r m e a v a n t

World J. Surg. Vol. 1, No. 1, January 1977

de c o n n a l t r e le t a u x de r6cidive d'ulc6re associ6 /t cette n o u v e l l e a p p r o c h e chirurgicale.

References

1. Blumenthal, I.S.: Digestive diseases as a national problem: III. Social cost of peptic ulcer. Gastroenterology 54:86, 1968 2. Forrest, A.P.M.: The treatment of duodenal ulcer by gastroenterostomy, gastroenterostomy and vagotomy and partial gastrectomy. Gastroenterologia 89:307, 1958 3. Cox, A.G.: Comparison of symptoms after vagotomy with gastrojejunostomy and partial gastrectomy. Br. Med. J. 1:288, 1968 4. Goligher, J.C., Pulvertaft, C.N, DeDombal, F.T., Conyers, J.H., Duthie, H.L., Feather, D.B., Latchmore, A.J.C., Shoesmith, J.H., Smiddy, F.C., Willson-Pepper, J.: Five to eight year results of Leeds-York controlled trial of elective surgery for duodenal ulcer. Br. Med. J. 2:781, 1968 5. Goligher, J.C., Pulvertaft, C.N., Watkinson, G.: Controlled trial of vagotomy and gastroenterostomy, vagotomy and antrectomy and subtotal gastrectomy in elective treatment of duodenal ulcer: Interim i'eport. Br. Med. J. 1:455, 1964 6. Goligher, J.C., Pulvertaft, C.N., Irvin, T.T., Johnston, D., Walker, B., Hall, R.A., Willson-Pepper, J., Matheson, T.S.: Five to eight year results of truncal vagotomy and pyloroplasty for duodenal ulcer. Br. Med. J. 1:7, 1972 7. Goligher, J.C.: The comparative results of different operations in the elective treatment of duodenal ulcer. Br. J. Surg. 57:78, 1970 8. Kennedy, F., MacKay, C., Bedi, B.S., Kay, A.W.: Truncal vagotomy and drainage for chronic duodenal ulcer disease: A controlled trial. Br. Med. J. 2:7l, 1973 9. Postlethwait, R.W.: Five year followup results of operations for duodenal Ulcer. Surg. Gynecol. Obstet. 137:387, 1973 10. Price, W.E., Grizzle, J.E., Postlethwait, R.W., Johnston, W.D., Grabicki, P.: Results of operation for duodenal ulcer. Surg. Gynecol. Obstet. 13l:233, 1970 11. Howard, R.J., Murphy, W.R., Humphrey, E.W.: A prospective study of the elective treatment of duodenal ulcer: Two to ten year followup study. Surgery 73:256, 1973 12. Jordan, P.H., Condon, R.E.: A prospective evaluation of vagotomy-pyloroplastyand vagotomy-antrectomy for treatment of duodenal ulcer. Ann. Surg. 172:547, 1970 13. Jordan, P.H.: A followup report of a prospective evaluation of vagotomy-pyloroplasty and vagotomy-antrectomy for treatment of duodenal ulcer. Ann. Surg. 180:259, 1974 14. Scott, H.W., Jr., Sawyers, J.L., Gobbel, W.G., Herrington, J.L., Edwards, L.W., Edward, W.H.: Vagotomy and antrectomy in surgical treatment of duodenal ulcer. Surg. Clin. North Am. 46:349, 1966 15. Thompson, B.W., and Read, R.C.: Long-term randomized prospective comparison of Finney and Heineke-Mikulicz pyloroplasty in patients having vagotomy for peptic ulceration. Am. J. Surg. 129:78, 1975 16. Kraft, R.O., Fry, W.J., Wilhelm, K.G., Ramson, H.K.: Selective gastric vagotomy. A critical appraisal. Arch. Surg. 95:625, 1967 17. Mason, M.C., Giles, G.R., Graham, N.G., Clark, C.G., Goligher, J.C.: An early assessment of selective and total vagotomy. Br. J. Surg. 55:677, 1968 18. Sawyers, J.L., Scott, W.H.J., Edwards, W.H., Shull, H.J., Law, D.H.: IV: Comparative studies of the clinical effects of truncal and selective gastric vagotomy. Am. J. Surg. 115:165, 1968 19. Kennedy, T., Connell, A.M.: Selective or truncal vagotomy? A double blind randomized controlled trial. Lancet 1:899, 1966

S. D. Feldman et al: Elective Surgery of Duodenal Ulcer 20. Kennedy, T., Connell, A.M., Love, A.H.G., MacRae, K.D., Spencer, E.F.A.: Selective or truncal vagotomy? Five year results of a double blind, random controlled trial. Br. J. Surg. 60: 944, 1973 21. Kronborg, O., Malstrome, J., Christiansen, P.M.: A comparison between the results of truncal and selective vagotomy in patients with duodenal ulcer. Scand. J. Gastroenterol. [Suppl.] 5:519, 1970 22. Johnston, D., Humphrey, C.S., Walker, B.E., Pulvertaft, C.N., Goligher, J.C.: Vagotomy without diarrhea. Br. Med. J. 3:788, 1972 23. Burge, H., MacLean, C., Stedeford, R., Pinn, G., Hollanders, D.: Selective vagotomy without drainage. An interim report. Br. Med. J. 3:690. 1969 24. Clarke, R.J., McFarland, J.B., Williams, J.A.: Gastric stasis and gastric ulcer after selective vagotomy without drainage procedure. Br. Med. J. 1:538, 1972 25. Sawyers, J.L., Scott, W.H.: Selective gastric vagotomy with antrectomy pyloroplasty. Ann. Surg. 174:541, 1971 26. Kennedy, T., Johnston, G.W., Love, A.H.G., Connell, A.M., Spencer, E.F.A.: Pyloroplasty versus gastrojejunostomy. Re-

INVITED COMMENTARY LLOYD M. NYHUS, M.D., F.A.C.S.

University of Illinois at the Medical Center Chicago, Illinois, U.S.A.

Surgeons interested in the problem of operative treatment of chronic duodenal ulcer are fortunate. A majority of patients are quite happy with the result of the treatment regardless of the type of procedure performed. Contrariwise, the surgeon's rate of satisfaction is always less than the patient's. Roughly 85-90 per cent of patients and 75-85 per cent of surgeons feel that over-all results following the various operative procedures are excellent. The review presented herein reflects this phenomenon of surgical therapy. Should we be surprised that after all these years, the gastric surgeons of the world continue to flounder in a morass of data impossible to interpret? For example, words such as antrectomy, hemigastrectomy and gastrectomy are used to describe the extent of resection. At the time of this writing, I believe that what may be an antrectomy to one surgeon will be a

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sults of a double-blind, randomized, controlled trial. Br. J. Surg. 60:949, 1973 Amdrup, E., Jensen, H. E.: Selective vagotomy of the parietal cell mass preserving innervation of the undrained antrum. Gastroenterology 59:522, 1970 Johnston, D., Wilkinson, A.R.: Highly selective vagotomy without drainage procedure in the treatment of duodenal ulcer. Br. J. Surg. 57:289, 1970 Amdrup, E., Jensen, H.E., Johnston, E., Walker, B.E., Goligher, J.C.: Clinical results of parietal cell vagotomy (highly selective vagotomy) two to four years after operation. Ann. Surg. 180:279, 1974 Goligher, J.C.: An overall view of the surgical treatment of duodenal ulcer. Adv. Surg. 8:1, 1974 Kronborg, O., Madsen, P.: A controlled, randomized trial of highly selective vagotomy versus selective vagotomy and pyIoroplasty in the treatment of duodenal ulcer. Gut 16:268, 1975 Wastell, C., Colin, J.F., MacNaughton, J.I., Gleeson, J.: Selective proximal vagotomy with or without pyloroplasty. Br. Med. J. 1:28, 1972

hemigastrectomy to another. How can we than in good conscience attempt comparisons? Parenthetically, a technic is available wherein a semblance of accuracy can be given to the determination of extent of gastric resection [1]. The fact that review articles inherently tend to be static contributes still further to the problem. In the foregoing article we read that in several reports the incidence of the dumping syndrome was low after one operative technic and high after another. However, these figures represent the incidence at the time of original review. Fortunately, it is a matter of fact that the incidence of the dumping syndrome (as well as postvagotomy diarrhea) decreases with the passage of time. Meaningful dumping problems in our postgastric surgery patients are found in less than 5 per cent of the patients, regardless of the type of operative procedure. Thus to quote the rather high incidence of dumping or postvagotomy diarrhea without further explanation is unfair. What is the true (life-time) recurrent ulcer rate of truncal vagotomy plus a drainage procedure following treatment of duodenal ulcer patients? This reviewer is impressed with the relatively short follow-up of patients in a majority of the reports selected for presentation. The 28 per cent recurrent ulcer rate

Review of elective surgical treatment of chronic duodenal ulcer.

World J. Surg. I, 9-17, 1977 Review of Elective Surgical Treatment of Chronic Duodenal Ulcer STEPHEN D . FELDMAN, M.D., LESLIE WISE, M.D., and WAL...
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