Br. J. Surg. Vol. 64 (1977) 332-335
The place of transthoracic vagotomy in the management of recurrent peptic ulceration J . E. H E D E , J . G . T E M P L E A N D J O H N M c F A R L A N D * SUMMARY
For the successful treatment of recurrent peptic ulceration confirmation of the presence of the ulcer by fibreoptic endoscopy is essential. Further investigation by barium meal and gastric acid secretion studies allows a rational surgical approach to be formulated. This process is illustrated by discussion of the investigative findings and the results of treatment in a series of 20 patients with recurrent peptic ulcer over a 5-year period. In onehalf of these patients a second abdominal operation was necessary, but in the other halfa transthoracic vagotomy alone gave equally good results.
THEproblem of recurrence after previous surgery for peptic ulceration is considerable. It has been estimated that about 1700 cases could be expected annually in the United Kingdom, and the numerous papers on the subject testify to the lack of agreement about the best method of treating this problem. Currently, vagotomy and a drainage procedure is fashionable as the initial operation and further efforts at vagotomy for recurrent ulcer, particularly by the transthoracic route, have been seriously questioned (Fawcett et al., 1969). Resection of part of the stomach plus the ulcer is often a more acceptable second operation and, if further vagal section is indicated, it is recommended that this should be performed by the abdominal route in spite of technical difficulties (Steinberg et al., 1975b). We believe that there is a balance to be found and that there is a place for revagotomy alone, for which the transthoracic route should be considered. This paper describes the surgical approach to the problem of recurrent peptic ulcer that has been employed in this unit over the past 5 years. This has involved a careful clinical and investigative assessment of each patient, which is similar to the schemes outlined by Griffen (1969) and Steinberg et al. (1975a, b).
Patients and methods Twenty patients undergoing reoperation for proved recurrent peptic ulcer following previous surgery for duodenal ulcer are the subjects of this report (Table I ) . Seventeen of these patients had undergone truncal vagotomy and pyloroplasty (TV and P) or truncal vagotomy and posterior gastro-enterostomy (TV and PGE) and 3 had undergone partial gastrectomy (PG). They were selected from patients presenting for investigation of recurrent symptoms after surgery on the upper gastro-intestinal tract. All patients with suspected recurrence were assessed with regard to establishing the presence of a definite peptic ulcer and whether it was associated with any of the following: 1. Gastric outlet obstruction. 2. Incomplete vagotomy. 3. Complications of the ulcer, e.g. bleeding, internal fistula. 4. Associated local abnormalities, e.g. bilious vomiting, hiatus hernia. Symptoms were classified according to Visick grades (Goligher et al., 1968a). Particular note was made of vomiting, both bilious and non-bilious. Persistent and troublesome nonbilious vomiting, especially after eating, was considered to be highly suggestive of defective gastric emptying. All patients had a barium meal performed. Careful note was taken of any evidence of gastric outlet obstruction and delayed
gastric emptying. Other contrast radiology was carried out when indicated. Fibreoptic examination with both end- and side-viewing instruments was performed routinely on all patients. Narrowing or severe deformity at the site of a previous pyloroplasty or a gastrojejunostomy stoma was recorded as representing possible gastric outlet obstruction. Gastric acid tests were carried out in a special unit regularly performing gastro-intestinal biochemical studies, and included basal acid output, pentagastrin-stimulated acid output and insulin-stimulated acid output. Insulin tests were interpreted according to Hollander’s criteria (1946), with division to early and late positive responses (Johnston et al., 1967). Positive responses were taken as evidence of incomplete vagotomy (Baron and Alexander-Williams, 1973) and if doubtful the tests were repeated. Following surgery for recurrent ulceration, further acid studies were done after a period of 6 months (Watkin and Duthie, 1971). Patients with a high basal acid output after previous gastric surgery had a serum gastrin assay to exclude the Zollinger-Ellison syndrome.
Results The results are detailed in Table I . Symptoms All 20 patients with proved recurrence presented with pain and were in Visick grades 111 or IV. Seven had non-bilious vomiting suggesting defective gastric emptying, 6 after TV and P, and 1 after TV and PGE, this latter patient also having had a haematemesis. In 3 patients who had had TV and PGE the vomiting was bilious in nature. Radiology Barium meal showed an active ulcer in 13 patients, in 7 after TV and P, in 4 after T V and PGE and in 2 after PG. Evidence of delayed gastric emptying with or without narrowing of the outlet was seen in 5 patients after TV and P and in 1 after TV and PGE. Hiatus hernia with reflex occurred in 2 patients after TV and P. Endoscopy A definite ulcer was seen in each of the 20 patients reported in this series, although in some patients a repeat examination was required before the ulcer was confirmed. Features suggesting gastric outlet obstruction were noted in 6 patients after TV and P and in 1 after TV and PGE. Gastric acid tests All patients had significant acid outputs after pentagastrin and 18 had positive insulin tests (15 early positive and 3 late positives). Of the 17 patients who had had a previous vagotomy, 15 were insulin-positive (all 9 after TV and P, 6 after TV and PGE) and the 2
* The Royal Southern Hospital, Liverpool. Address for reprints : John McFarland, Royal Southern Hospital, Liverpool. Present address of J. E. Hede: Toowoomba General Hospital, Queensland, Australia. Present address of J. G . Temple: Department of Surgery, University of Manchester, Hope Hospital, Salford.
Recurrent peptic ulceration
333
Table I: PATIENT ASSESSMENT, SURGICAL APPROACH AND RESULTS Patients No. Sex Age Diagnosis and assessment Previous TV and P 1 M 36 DU, hiatus hernia 2 M 61 DU 3 F 37 DU 4 M 63 DU, gastric outlet obstruction 5 M 30 DU, gastric outlet obstruction, HH 6 M 39 DU, gastric outlet obstruction 7 M 40 DU, gastric outlet obstruction 8 M 49 DU, gastric outlet obstruction 9 M 31 DU, gastric outlet obstruction
Preop. insulin test Positive/ Early/ PAO& negative late mmol/h
++ +
Operation
E E E L E
25.4 17.7 11.4 11.6 5.1
E E E E
3.9 6.6 22.6 21.5
TTV, HH repair TTV TTV AV, antrectomy AV, antrectomy HH repair AV, antrectomy AV, antrectomy AV, antrectomy AV, antrectomy
+
E E E L E L
14.8 1.8 26.8 23.2 14.3 12.3
Tl-V TTV TTV TTV AV, antrectomy AV, antrectomy
-
-
+ +
+
+ + +
Previous TV and PGE 10 M 54 SU 11 M 36 SU 49 SU 12 F 13 M 33 SU 14 M 52 SU, bilious vomiting 15 F 39 SU, gastric outlet obstruction, bleeding ulcer 16 M 31 SU, bilious vomiting 41 SU, bilious vomiting 17 M
+ + + ++
Previous PG 18 M 65 19 M 52 20 M 60
+ + +
-
0 4.0
Postop. insulin test Positive/ P A 0 & negative mmol/h
NT
0 0 -
-
0.7
NT
-
NT
-
-
0.5
NT
-
0.4
Follow-up Visick grading
I (2 yr) I ( 1 yr) I (la yr) 1(2 yr) 11 (24 (Yd (1 Yr) 1 ( 3 yr) I (4t yr) I1 (9 mth) J
Antrectomy Antrectomy
11.2 TTV E 0 I (4 yr) 0-6 I ( I t yr) E 6.3 TTV E 9.7 TTV NT I(24 yr) PAO&, Peak acid output to insulin after subtraction of basal acid output; TV and P, truncal vagotomy and pyloroplasty (Heineke-Mickulicz); TV and PGE, truncal vagotomy and posterior gastro-enterostomy; PG, partial gastrectomy (Polya); DU, duodenal ulcer; SU, stoma1 ulcer; TTV, transthoracic vagotomy; HH, hiatus hernia; AV, abdominal vagotomy; NT, not tested. SU SU SU
who were insulin-negative had bilious vomiting after TV and PGE. Two patients had raised basal acid outputs after partial gastrectomy and in both of these a serum gastrin assay was normal. Gastric outlet obstruction Whenever symptoms, radiology or endoscopy suggested its presence, an obstructed gastric outlet was taken as being a significant factor in need of correction. It was considered to exist in 6 of 9 patients after TV and P and in 1 of 8 patients after TV and PGE. Surgical approach The rationale of the surgical approach is shown in Table IZ and may be summarized by saying that if there was evidence that gastric vagal innervation was still intact, a transthoracic vagotomy was undertaken unless there was a reason for operation by the abdominal route. Transthoracic vagotomy was performed by a standard technique (Silver, 1969). After gastric resection (antrectomy) preference for reconstruction was by the Billroth I method, which was possible in 7 cases. In 3 patients marked residual narrowing and scarring at the pylorus and the first part of the duodenum made a Billroth II reconstruction necessary. Transthoracic revagotomy alone was performed in 10 patients who had an incomplete vagotomy but nothing to suggest a need for further abdominal surgery-in 4 after TV and PGE, in 3 after TV and P and in 3 after PG. Abdominal revagotomy and antrectomy was performed in 8 patients with an incomplete
Table II: RATIONALE OF SURGICAL APPROACH FOR RECURRENT PEPTIC ULCERATION Results of assessment Symptoms, radiology, Acid studies endoscom Surgical approach Incomplete Gastric outlet obstruction Antrectomy and vagotomyt or other reason* for abdominal abdominal reoperation revagotomy Transthoracic revagotomy Complete Antrectomy vagotomyt Complete Gastric outlet obstruction Appropriate surgery vagotomyt: or other reason* for and abdominal abdominal reoperation vagotomy Incomplete Transthoracic vagotomy vaaotomvi:
* Other reasons for abdominal operation include bilious vomiting, bleeding ulcer, internal fistula and possibly gastric ulcer and suspicion of malignancy. Original operation (all for DU): t Vagotomy and pyloroplasty or vagotomy and gastro-enterostomy ;t: partial gastrectomy. vagotomy; 2 of these had had a previous TV and PGE, the abdominal operation being for bilious vomiting in one and bleeding ulcer with gastric outlet obstruction in the other, and the other 6 had had a previous TV and P, the abdominal operation being for gastric outlet obstruction in all. The 2 patients with a complete vagotomy after previous TV and PGE had an antrectomy alone. In addition, 2 patients had a hiatus hernia repair at their second operation.
334
J. E. Hede et al.
Clinical results All patients were well when seen at their last follow-up (periods ranging from 9 months to 4+ years), with 15 being in Visick grade I and 5 in grade I1 (Table I ) . There was no mortality or significant morbidity, but one patient had an oesophageal tear during abdominal revagotomy. Those patients who consented to postoperative insulin tests were all negative, 7 after transthoracic revagotomy and 4 after abdominal revagotomy.
Discussion The aetiology of recurrent peptic ulceration is multifactorial (Bruce et al., 1959; Griffen, 1969). The following mechanisms have been postulated (Dragstedt, 1969): 1. Inadequate gastric emptying. 2. Incomplete vagotomy. 3. Unknown antral factors. 4. Zollinger-Ellison syndrome. Accuracy of diagnosis is essential and, since there is no place for medical treatment in this situation (Balint et al., 1957), failure to achieve a correct diagnosis will mean some patients may have unnecessary surgery with exposure to its consequent sequelae (Stuart and Hoerr, 1971). The superiority of endoscopy in investigating recurrent symptoms after peptic ulcer surgery is well established (Cotton et al., 1973; Steinberg et al., 197513). The present authors’ experience confirms this. All 20 patients in this series had a recurrent ulcer seen by endoscopy while only 13 had radiological evidence of their ulcer, and we consider it inadvisable to operate for peptic ulceration unless this is proved by endoscopy. However, barium meal examination is still essential, particularly in detecting defective gastric emptying, and further contrast radiology may be necessary to exclude other pathology (Toye and AlexanderWilliams, 1969). The insulin test of Hollander is a reliable index of the risk of recurrent ulcer after vagotomy (Johnston et al., 1967), and negative results are uncommon in this situation (2 patients in our series). Positive results indicating incomplete vagotomy occur in many patients without recurrent ulceration. However, when a recurrent ulcer is accompanied by a positive response, we feel that a revagotomy is required in the surgical treatment. The importance of performing the full range of acid studies has been emphasized by Baron and Alexander-Williams (1973). Gastric outlet obstruction and defective gastric emptying causing antral distension and a raised serum gastrin may occur after previous peptic ulcer surgery, especially vagotomy and drainage procedures (Bryant et a]., 1967). In large series of vagotomized patients, higher recurrence rates have been found after HeinekeMickulicz pyloroplasty than after Finney pyloroplasty (Bryant et al., 1967) and after pyloroplasty procedures compared to gastro-enterostomy (Goligher et al., 1968b; Gillett and de Burgh, 1974). It is possible that this is due to the less adequate drainage offered by the former operation in each instance. Davies et al. (1974) have shown gastric emptying to be slower after Heineke-Mickulicz pyloroplasty compared to other drainage procedures. Recurrent ulceration with continuous well-defined vomiting, both bilious and non-bilious, is likely to be associated with antral distension due to either bile
accumulation in the stomach or gastric outlet obstruction. With both types of vomiting it is safer to presume that antral factors are involved and to perform antrectomy. This will remove the offending antrum and should relieve the cause of the vomiting as well. We realize our assessment of gastric outlet obstruction by symptomatology, radiology and endoscopy cannot be entirely accurate and there are more complex and exact methods of confirming this (Griffith et al., 1968). However, our clinical methods are unlikely to miss the existence of established outlet obstruction and it is preferable to accept its presence in this situation if there is anything to suggest it. In this series gastric outlet obstruction was considered to exist in just over one-third of the patients. It occurred only after previous vagotomy and drainage, being more common after TV and P than after TV and PGE. Failure to recognize its presence could account for the previous contrary reports of revagotomy procedures alone in recurrent peptic ulceration (Fawcett et al., 1969). It was possible to perform a revagotomy alone by the transthoracic route in 10 of our patients (50 per cent) and this has produced excellent results. There was no specific reason to perform further abdominal surgery in these patients, and thus they were not subjected to the possible difficulties and side-effects of this. Transthoracic vagotomy is a safe operation and we can confirm the findings of others as to the efficacy of this procedure in the management of selected cases of recurrent peptic ulcer (Crile and Brown, 1951; Jackson and Berkas, 1966; Cleator et al., 1974). Fawcett et al. (1969) have criticized this operation because the actual intra-abdominal pathology cannot be seen. Their patients were not investigated using modern fibreoptic endoscopy, which we consider most important in the assessment of subjects with recurrent dyspepsia after previous gastric surgery. Furthermore, these authors found that over one-half of their patients were still insulin-positive postoperatively. The Committee on Surgical Procedures (1952) stated that the insulin test was positive in 33 per cent of cases of transthoracic vagotomy compared with only 20 per cent of abdominal vagotomies. In view of the large number of centres contributing to this report it is not surprising that the Committee also stated that this information could have been erroneous in part because of inadequacies in the test procedures and evaluation. Certainly in our series the patients who were insulin tested after transthoracic vagotomy had an adequate reduction in acid secretion and, what is more important, a good symptomatic response. The Committee on Surgical Procedures (1952) considered that vagotomy alone was of definite value in the treatment of recurrent peptic ulcer and that there was no evidence that abdominal vagotomy had any specific advantage over the transthoracic route. In conclusion, it has been possible to achieve uniformly successful results in our patients with recurrent peptic ulceration by accurate diagnosis and by identification and correction of potential underlying causes and local abnormalities, namely, incomplete vagotomy, gastric outlet obstruction and bilious vomiting. It is unwise to adopt a single policy of treatment and optimum results are more likely with planned surgery along the lines outlined above. There remains a place for transthoracic vagotomy in this approach.
Recurrent peptic ulceration References
et al. (1968b) Clinical comparison of vagotomy and pyloroplasty with other forms of elective surgery for duodenal ulcer. Br. Med. J. 2, 787-789. GRIPFEN w. 0.(1969) Recurrent ulcer. In: ALEXANDER-WILLIAMS J. and cox A. G. (ed.) After Vagotomy. London, Butterworths, pp. 188-196. GRIFFITH 0. H., OWEN G. M., CAMBELL H. et al. (1968) Gastric emptying in health and gastroduodenal disease. Gastroenterology 54, 1-7. HOLLANDER F. (1946) The insulin test for the presence of intact nerve fibers after vagal operations for peptic ulcer. Gastroenterology 7, 607414. JACKSON F. R. and BERKAS E. M. (1966) Transthoracic vagotomy for recurrent peptic ulcer. Mich. Med. 65, 838. JOHNSTON D., THOMAS D. G., CHECKETTS R. 0. et al. (1967) An assessment of postoperative testing for completeness of vagotomy. Br. J. Surg. 54, 831-833. SILVER D. (1969) Transthoracic vagotomy. In: GIBBON J. H., SABISTON D. c. and SPENCER F. c. (ed.) Surgery of the Chest, 2nd ed. Philadelphia, Saunders, pp. 303-304. STEINBERG D. M., GREEN G., TOYE D. K. M. et al. (1975a) The accuracy of methods of diagnosis in patients with suspected recurrent ulcer after vagotomy. Aust. NZ. J. Surg. 45, 252-256. STEINBERG D. M., MASSELINK B. A. and ALEXANDER-WILLIAMS J. (1975b) Assessment and treatment of recurrent peptic ulceration. Ann. R. Coll. Surg. Engl. 56, 135-140. STUART M. and HOERR s. 0. (1971) Recurrent peptic ulcer following primary operations with vagotomy for duodenal ulcer. Arch. Surg. 103, 129-132. TOYE D. K. M. and ALEXANDER-WILLIAMS J. (1969) Radiology in the assessement of failures. In : ALEXANDER-WILLIAMS J. and cox A. G. (ed.). After Vagotomy. London, Butterworths, pp. 306-322. WATKIN D. F. L. and DUTHIE H. L. (1971) Changes in the postoperative insulin test in relation to recurrent duodenal ulceration. Gut 12, 303-310. WELLS c. and SILBERMAN R. (1960) Transthoracic vagotomy for stoma1 ulceration. Lancet 1, 406-407.
GOLIGHER J. C., PULVERTAFT C. N., DE DOMBAL F. T.
et al. (1957) The management of anastomotic ulcer. Lancet 2, 551-555. BARON J. G. and ALEXANDER-WILLIAMS J. (1973) Gastric secretion tests. In: TAYLOR s. (ed.) Recent Advances in Surgery, No. 8. Edinburgh, Churchill Livingstone, pp. 166-198. BRUCE J., CARD w. I., MARKS I. N. et al. (1959) The rationale of selective surgery in the treatment of duodenal ulcer. J. R. CON.Surg. Edinb. 4, 85-98. BRYANT W. M., KLEIN D. and GRIFFEN W. 0. (1967) The role Of vagotomy in duodenal ulcer surgery. Surgery 61,864-867. CLEATOR I. G . M., HOLUBITSKY I. B. and -SON R. c. (1974) Anastomotic ulceration. Ann. Surg. 179, 339-351. COMMITTEE ON SURGICAL PROCEDURES (1952) Report Of the National Committee on Peptic Ulcer of the American Gastroenterological Association. Gastroenterology 22, 295-500. COTTON P. B., ROSENBERG M. T., AXON A. T. R. et al. (1973) Diagnostic yield of fibre-optic endoscopy in the operated stomach. Br. J. Surg. 60, 629632. CRILE G. J. and BROWN G. M. (1951) Vagotomy as a treatment for marginal ulcer. Gastroenterology 17, 14-19. DAVIES w. T., GRIPFITH G. H., OWEN G. M. et al. (1974) The effect of vagotomy and drainage operations on the rate of gastric emptying in duodenal ulcer patients. Br. J. Surg. 61, 509515. DRAGSTEDT L. R. (1969) Recurrent ulceration after vagotomy. In: HARKINS H. N. and NYHUS L. M. (ed.) Surgery of the Stomach and Duodenum. 2nd ed. London, Churchill, pp. 547-548. FAWCETT A, N., JOHNSTON D. and DUTHIE H. L. (1969) Revagotomy for recurrent ulcer after vagotomy and drainage for duodenal ulcer. Br. J. Surg. 56, 111-1 16. GILLETT D. J. and DE BURGH M. M. (1974) Recurrent ulceration after gastroenterostomy or pyloroplasty with complete and incomplete vagotomy. Am. J . Surg. 127, 650452. GOLIGHER J. c., PULVERTAFT c. N., DE DOMBAL F. T. et al. (1968a) Five- to eight-year results of Leeds-York controlled trial of elective surgery for duodenal ulcer. Br. Med. J. 2, 781787. BALINT J. A., COOPER G. W.,
PRICE E. C. V.
335
The place of transthoracic vagotomy in the management of recurrent peptic ulceration J . E. H E D E , J . G . T E M P L E A N D J O H N M c F A R L A N D * SUMMARY
For the successful treatment of recurrent peptic ulceration confirmation of the presence of the ulcer by fibreoptic endoscopy is essential. Further investigation by barium meal and gastric acid secretion studies allows a rational surgical approach to be formulated. This process is illustrated by discussion of the investigative findings and the results of treatment in a series of 20 patients with recurrent peptic ulcer over a 5-year period. In onehalf of these patients a second abdominal operation was necessary, but in the other halfa transthoracic vagotomy alone gave equally good results.
THEproblem of recurrence after previous surgery for peptic ulceration is considerable. It has been estimated that about 1700 cases could be expected annually in the United Kingdom, and the numerous papers on the subject testify to the lack of agreement about the best method of treating this problem. Currently, vagotomy and a drainage procedure is fashionable as the initial operation and further efforts at vagotomy for recurrent ulcer, particularly by the transthoracic route, have been seriously questioned (Fawcett et al., 1969). Resection of part of the stomach plus the ulcer is often a more acceptable second operation and, if further vagal section is indicated, it is recommended that this should be performed by the abdominal route in spite of technical difficulties (Steinberg et al., 1975b). We believe that there is a balance to be found and that there is a place for revagotomy alone, for which the transthoracic route should be considered. This paper describes the surgical approach to the problem of recurrent peptic ulcer that has been employed in this unit over the past 5 years. This has involved a careful clinical and investigative assessment of each patient, which is similar to the schemes outlined by Griffen (1969) and Steinberg et al. (1975a, b).
Patients and methods Twenty patients undergoing reoperation for proved recurrent peptic ulcer following previous surgery for duodenal ulcer are the subjects of this report (Table I ) . Seventeen of these patients had undergone truncal vagotomy and pyloroplasty (TV and P) or truncal vagotomy and posterior gastro-enterostomy (TV and PGE) and 3 had undergone partial gastrectomy (PG). They were selected from patients presenting for investigation of recurrent symptoms after surgery on the upper gastro-intestinal tract. All patients with suspected recurrence were assessed with regard to establishing the presence of a definite peptic ulcer and whether it was associated with any of the following: 1. Gastric outlet obstruction. 2. Incomplete vagotomy. 3. Complications of the ulcer, e.g. bleeding, internal fistula. 4. Associated local abnormalities, e.g. bilious vomiting, hiatus hernia. Symptoms were classified according to Visick grades (Goligher et al., 1968a). Particular note was made of vomiting, both bilious and non-bilious. Persistent and troublesome nonbilious vomiting, especially after eating, was considered to be highly suggestive of defective gastric emptying. All patients had a barium meal performed. Careful note was taken of any evidence of gastric outlet obstruction and delayed
gastric emptying. Other contrast radiology was carried out when indicated. Fibreoptic examination with both end- and side-viewing instruments was performed routinely on all patients. Narrowing or severe deformity at the site of a previous pyloroplasty or a gastrojejunostomy stoma was recorded as representing possible gastric outlet obstruction. Gastric acid tests were carried out in a special unit regularly performing gastro-intestinal biochemical studies, and included basal acid output, pentagastrin-stimulated acid output and insulin-stimulated acid output. Insulin tests were interpreted according to Hollander’s criteria (1946), with division to early and late positive responses (Johnston et al., 1967). Positive responses were taken as evidence of incomplete vagotomy (Baron and Alexander-Williams, 1973) and if doubtful the tests were repeated. Following surgery for recurrent ulceration, further acid studies were done after a period of 6 months (Watkin and Duthie, 1971). Patients with a high basal acid output after previous gastric surgery had a serum gastrin assay to exclude the Zollinger-Ellison syndrome.
Results The results are detailed in Table I . Symptoms All 20 patients with proved recurrence presented with pain and were in Visick grades 111 or IV. Seven had non-bilious vomiting suggesting defective gastric emptying, 6 after TV and P, and 1 after TV and PGE, this latter patient also having had a haematemesis. In 3 patients who had had TV and PGE the vomiting was bilious in nature. Radiology Barium meal showed an active ulcer in 13 patients, in 7 after TV and P, in 4 after T V and PGE and in 2 after PG. Evidence of delayed gastric emptying with or without narrowing of the outlet was seen in 5 patients after TV and P and in 1 after TV and PGE. Hiatus hernia with reflex occurred in 2 patients after TV and P. Endoscopy A definite ulcer was seen in each of the 20 patients reported in this series, although in some patients a repeat examination was required before the ulcer was confirmed. Features suggesting gastric outlet obstruction were noted in 6 patients after TV and P and in 1 after TV and PGE. Gastric acid tests All patients had significant acid outputs after pentagastrin and 18 had positive insulin tests (15 early positive and 3 late positives). Of the 17 patients who had had a previous vagotomy, 15 were insulin-positive (all 9 after TV and P, 6 after TV and PGE) and the 2
* The Royal Southern Hospital, Liverpool. Address for reprints : John McFarland, Royal Southern Hospital, Liverpool. Present address of J. E. Hede: Toowoomba General Hospital, Queensland, Australia. Present address of J. G . Temple: Department of Surgery, University of Manchester, Hope Hospital, Salford.
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333
Table I: PATIENT ASSESSMENT, SURGICAL APPROACH AND RESULTS Patients No. Sex Age Diagnosis and assessment Previous TV and P 1 M 36 DU, hiatus hernia 2 M 61 DU 3 F 37 DU 4 M 63 DU, gastric outlet obstruction 5 M 30 DU, gastric outlet obstruction, HH 6 M 39 DU, gastric outlet obstruction 7 M 40 DU, gastric outlet obstruction 8 M 49 DU, gastric outlet obstruction 9 M 31 DU, gastric outlet obstruction
Preop. insulin test Positive/ Early/ PAO& negative late mmol/h
++ +
Operation
E E E L E
25.4 17.7 11.4 11.6 5.1
E E E E
3.9 6.6 22.6 21.5
TTV, HH repair TTV TTV AV, antrectomy AV, antrectomy HH repair AV, antrectomy AV, antrectomy AV, antrectomy AV, antrectomy
+
E E E L E L
14.8 1.8 26.8 23.2 14.3 12.3
Tl-V TTV TTV TTV AV, antrectomy AV, antrectomy
-
-
+ +
+
+ + +
Previous TV and PGE 10 M 54 SU 11 M 36 SU 49 SU 12 F 13 M 33 SU 14 M 52 SU, bilious vomiting 15 F 39 SU, gastric outlet obstruction, bleeding ulcer 16 M 31 SU, bilious vomiting 41 SU, bilious vomiting 17 M
+ + + ++
Previous PG 18 M 65 19 M 52 20 M 60
+ + +
-
0 4.0
Postop. insulin test Positive/ P A 0 & negative mmol/h
NT
0 0 -
-
0.7
NT
-
NT
-
-
0.5
NT
-
0.4
Follow-up Visick grading
I (2 yr) I ( 1 yr) I (la yr) 1(2 yr) 11 (24 (Yd (1 Yr) 1 ( 3 yr) I (4t yr) I1 (9 mth) J
Antrectomy Antrectomy
11.2 TTV E 0 I (4 yr) 0-6 I ( I t yr) E 6.3 TTV E 9.7 TTV NT I(24 yr) PAO&, Peak acid output to insulin after subtraction of basal acid output; TV and P, truncal vagotomy and pyloroplasty (Heineke-Mickulicz); TV and PGE, truncal vagotomy and posterior gastro-enterostomy; PG, partial gastrectomy (Polya); DU, duodenal ulcer; SU, stoma1 ulcer; TTV, transthoracic vagotomy; HH, hiatus hernia; AV, abdominal vagotomy; NT, not tested. SU SU SU
who were insulin-negative had bilious vomiting after TV and PGE. Two patients had raised basal acid outputs after partial gastrectomy and in both of these a serum gastrin assay was normal. Gastric outlet obstruction Whenever symptoms, radiology or endoscopy suggested its presence, an obstructed gastric outlet was taken as being a significant factor in need of correction. It was considered to exist in 6 of 9 patients after TV and P and in 1 of 8 patients after TV and PGE. Surgical approach The rationale of the surgical approach is shown in Table IZ and may be summarized by saying that if there was evidence that gastric vagal innervation was still intact, a transthoracic vagotomy was undertaken unless there was a reason for operation by the abdominal route. Transthoracic vagotomy was performed by a standard technique (Silver, 1969). After gastric resection (antrectomy) preference for reconstruction was by the Billroth I method, which was possible in 7 cases. In 3 patients marked residual narrowing and scarring at the pylorus and the first part of the duodenum made a Billroth II reconstruction necessary. Transthoracic revagotomy alone was performed in 10 patients who had an incomplete vagotomy but nothing to suggest a need for further abdominal surgery-in 4 after TV and PGE, in 3 after TV and P and in 3 after PG. Abdominal revagotomy and antrectomy was performed in 8 patients with an incomplete
Table II: RATIONALE OF SURGICAL APPROACH FOR RECURRENT PEPTIC ULCERATION Results of assessment Symptoms, radiology, Acid studies endoscom Surgical approach Incomplete Gastric outlet obstruction Antrectomy and vagotomyt or other reason* for abdominal abdominal reoperation revagotomy Transthoracic revagotomy Complete Antrectomy vagotomyt Complete Gastric outlet obstruction Appropriate surgery vagotomyt: or other reason* for and abdominal abdominal reoperation vagotomy Incomplete Transthoracic vagotomy vaaotomvi:
* Other reasons for abdominal operation include bilious vomiting, bleeding ulcer, internal fistula and possibly gastric ulcer and suspicion of malignancy. Original operation (all for DU): t Vagotomy and pyloroplasty or vagotomy and gastro-enterostomy ;t: partial gastrectomy. vagotomy; 2 of these had had a previous TV and PGE, the abdominal operation being for bilious vomiting in one and bleeding ulcer with gastric outlet obstruction in the other, and the other 6 had had a previous TV and P, the abdominal operation being for gastric outlet obstruction in all. The 2 patients with a complete vagotomy after previous TV and PGE had an antrectomy alone. In addition, 2 patients had a hiatus hernia repair at their second operation.
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J. E. Hede et al.
Clinical results All patients were well when seen at their last follow-up (periods ranging from 9 months to 4+ years), with 15 being in Visick grade I and 5 in grade I1 (Table I ) . There was no mortality or significant morbidity, but one patient had an oesophageal tear during abdominal revagotomy. Those patients who consented to postoperative insulin tests were all negative, 7 after transthoracic revagotomy and 4 after abdominal revagotomy.
Discussion The aetiology of recurrent peptic ulceration is multifactorial (Bruce et al., 1959; Griffen, 1969). The following mechanisms have been postulated (Dragstedt, 1969): 1. Inadequate gastric emptying. 2. Incomplete vagotomy. 3. Unknown antral factors. 4. Zollinger-Ellison syndrome. Accuracy of diagnosis is essential and, since there is no place for medical treatment in this situation (Balint et al., 1957), failure to achieve a correct diagnosis will mean some patients may have unnecessary surgery with exposure to its consequent sequelae (Stuart and Hoerr, 1971). The superiority of endoscopy in investigating recurrent symptoms after peptic ulcer surgery is well established (Cotton et al., 1973; Steinberg et al., 197513). The present authors’ experience confirms this. All 20 patients in this series had a recurrent ulcer seen by endoscopy while only 13 had radiological evidence of their ulcer, and we consider it inadvisable to operate for peptic ulceration unless this is proved by endoscopy. However, barium meal examination is still essential, particularly in detecting defective gastric emptying, and further contrast radiology may be necessary to exclude other pathology (Toye and AlexanderWilliams, 1969). The insulin test of Hollander is a reliable index of the risk of recurrent ulcer after vagotomy (Johnston et al., 1967), and negative results are uncommon in this situation (2 patients in our series). Positive results indicating incomplete vagotomy occur in many patients without recurrent ulceration. However, when a recurrent ulcer is accompanied by a positive response, we feel that a revagotomy is required in the surgical treatment. The importance of performing the full range of acid studies has been emphasized by Baron and Alexander-Williams (1973). Gastric outlet obstruction and defective gastric emptying causing antral distension and a raised serum gastrin may occur after previous peptic ulcer surgery, especially vagotomy and drainage procedures (Bryant et a]., 1967). In large series of vagotomized patients, higher recurrence rates have been found after HeinekeMickulicz pyloroplasty than after Finney pyloroplasty (Bryant et al., 1967) and after pyloroplasty procedures compared to gastro-enterostomy (Goligher et al., 1968b; Gillett and de Burgh, 1974). It is possible that this is due to the less adequate drainage offered by the former operation in each instance. Davies et al. (1974) have shown gastric emptying to be slower after Heineke-Mickulicz pyloroplasty compared to other drainage procedures. Recurrent ulceration with continuous well-defined vomiting, both bilious and non-bilious, is likely to be associated with antral distension due to either bile
accumulation in the stomach or gastric outlet obstruction. With both types of vomiting it is safer to presume that antral factors are involved and to perform antrectomy. This will remove the offending antrum and should relieve the cause of the vomiting as well. We realize our assessment of gastric outlet obstruction by symptomatology, radiology and endoscopy cannot be entirely accurate and there are more complex and exact methods of confirming this (Griffith et al., 1968). However, our clinical methods are unlikely to miss the existence of established outlet obstruction and it is preferable to accept its presence in this situation if there is anything to suggest it. In this series gastric outlet obstruction was considered to exist in just over one-third of the patients. It occurred only after previous vagotomy and drainage, being more common after TV and P than after TV and PGE. Failure to recognize its presence could account for the previous contrary reports of revagotomy procedures alone in recurrent peptic ulceration (Fawcett et al., 1969). It was possible to perform a revagotomy alone by the transthoracic route in 10 of our patients (50 per cent) and this has produced excellent results. There was no specific reason to perform further abdominal surgery in these patients, and thus they were not subjected to the possible difficulties and side-effects of this. Transthoracic vagotomy is a safe operation and we can confirm the findings of others as to the efficacy of this procedure in the management of selected cases of recurrent peptic ulcer (Crile and Brown, 1951; Jackson and Berkas, 1966; Cleator et al., 1974). Fawcett et al. (1969) have criticized this operation because the actual intra-abdominal pathology cannot be seen. Their patients were not investigated using modern fibreoptic endoscopy, which we consider most important in the assessment of subjects with recurrent dyspepsia after previous gastric surgery. Furthermore, these authors found that over one-half of their patients were still insulin-positive postoperatively. The Committee on Surgical Procedures (1952) stated that the insulin test was positive in 33 per cent of cases of transthoracic vagotomy compared with only 20 per cent of abdominal vagotomies. In view of the large number of centres contributing to this report it is not surprising that the Committee also stated that this information could have been erroneous in part because of inadequacies in the test procedures and evaluation. Certainly in our series the patients who were insulin tested after transthoracic vagotomy had an adequate reduction in acid secretion and, what is more important, a good symptomatic response. The Committee on Surgical Procedures (1952) considered that vagotomy alone was of definite value in the treatment of recurrent peptic ulcer and that there was no evidence that abdominal vagotomy had any specific advantage over the transthoracic route. In conclusion, it has been possible to achieve uniformly successful results in our patients with recurrent peptic ulceration by accurate diagnosis and by identification and correction of potential underlying causes and local abnormalities, namely, incomplete vagotomy, gastric outlet obstruction and bilious vomiting. It is unwise to adopt a single policy of treatment and optimum results are more likely with planned surgery along the lines outlined above. There remains a place for transthoracic vagotomy in this approach.
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