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Surgical management of peptic ulcer
Surgical
Management
of Peptic Ulcer L E SAVAGE, C B McVAY,
In 1949, vagotomy and gastroenterostomy were initially utilized only in the management of patients seriously ill with peptic ulcer. During the subsequent decade, vagotomy with some variety of drainage procedure has been performed with increasing frequency. By 1959, the vast majority of surgical candidates with peptic ulcer were managed with this operation. Thus, for twenty years we have been able to observe and carefully evaluate patients who have been treated with vagotomy and a drainage operation for all of the complications of peptic ulcer. Finally, this operation has been our first-line procedure over many years for both gastric and duodenal ulceration, including most of their acute and chronic variants. Clinical
Data
This series consists of 211 patients having either vagotomy with subtotal gastrectomy or vagotomy with a drainage procedure, and is entirely unselected, with the exception that initially only the dire-risk patient received the latter operation. It is also a consecutive series of patients with vagotomy, exclusive of a few patients who were eliminated from the study because their peptic ulcer was a part of a much more serious disease complex, such as pancreatic carcinoma or gastric cancer. The operative approach was identical in each case. A transverse upper abdominal incision was employed, and after the abdominal viscera were thoroughly inspected, a Penrose drain was placed about the abdominal esophagus for gentle traction. The triangular ligament of the left lobe of the liver was frequently incised for easier mobilization of the vagi. The celiac division of the right vagus and the hepatic branch of the left vagus, as illustrated by Harkins et al [I], were extremely useful landmarks in the location and performance of a total truncal vagotomy. Silver clips were placed and 3 to 4 cm of the vagi were resected, Circumferential dissection of the abdominal esophagus was then carried out to obviate the possibility of retained vagal fibers. The pyloroplasty, with rare exception, was of the Heineke-Mikulicz type with a onelayer silk closure employed most frequently [2]. A From the Department of Surgery, University of South Dakota School of Medicine. and the Yankton Clinic, Yankton. South Dakota. Presented at the Tenth Annual Meetina of the Society for Surnerv of the Alimentary Tract, New York, New York, July 12 and 13, 1969.
Vol. 119, February 1970
MD, MD,
Yankton, Yankton,
South South
Dakota Dakota
gastroenterostomy,
if utilized, was usually anterior and isoperistaltic. In either drainage procedure we hoped to achieve a 2 to 4 cm stoma. Frequently, a Stamm gastrostomy was employed, using a 5 cc Number 22 Foley catheter. A musculofascial peritoneal closure in one layer with stainless steel sutures was customary, and the subcutaneous tissue and skin were closed with fine silk. The patients were usually started on liquids by the third postoperative day and were dismissed between the sixth and tenth day after surgery. Age and Sex. As noted in Table I, the majority of the 211 patients (71.5 per cent) were over fifty years of age when they were operated upon. The ratio of male to female patients was about 3 to 1. Preoperative Signs and Symptoms. Table II points out the usual high frequency of pain in patients with peptic ulcer, but the more striking fact is that 54 per cent of these patients had active bleeding or had documentation of previous bleeding when admitted to the hospital for surgery. Only one patient with acute perforation was treated with a definitive vagotomy procedure initially. It has been usual for a patient with previous perforation to undergo a definitive operation, and twenty-five such patients are included in this series. Upper Gastrointestinal Hemorrhage. A tabular summary of patients with upper gastrointestinal hemorrhage is noted in Table III. Hemorrhage was graded on the basis of massive (transfusion of more than five units of whole blood), moderate (less than five units of whole blood), or a positive history with or without previous transfusion. Of 211 patients, 115 presented with upper gastrointestinal hemorrhage (54.0 per cent). The serious nature of this problem is noted in the 49 per cent who received five or more units of whole blood prior to surgery. The mortality in 115 patients with upper gastrointestinal hemorrhage was 1.7 per cent. Variety of Operations. In Table IV it is noted that the great majority of patients (77.2 per cent) underwent vagotomy and pyloroplasty. Vagotomy alone was utilized four times in the management of recurrent stoma1 ulcer. Vagotomy and gastrojejunostomy were utilized thirty-seven times and continue to be a most useful alternative in a patient with a severely indurated duodenum in whom pyloroplasty may be hazardous. Any combination of vagotomy and subtotal gastric re191
Savage and McVay TABLE
Age
I
and
Sax of 211
Data
Patients
Number of Patients
TABLE Per cent
____
~_. _.-. .~~~-.
._._
Positive history
39
34.0
0.4
Moderate*
20
17 0
20-29
5
2.4
Massive t
56
49 0
30-39
13
6.2
40-49
41
19.5
50-59
69
32.7*
60-69
51
24.2*
70-79
27
12.7*
4
1.9*
Mortality
Male Female
160
75.8
51
24.2
t Transfusion of more than five units whole blood.
section as primary surgical treatment for peptic ulcer has not been performed for more than a decade at the Yankton Clinic. Simultaneous duodenal and gastric ulcers were seen in ten patients who were all treated with vagotomy, pyloroplasty, and not infrequently with excision of the gastric ulcer. It is noteworthy that most benign gastric ulcers were managed with vagotomy and pyloroplasty. Operative Findings. A documentation of the operative findings is presented in Table V. Duodenal ulcer accounted for 76.3 per cent of the pathologic disorders in this series; thirty-four of these 161 duodenal ulcers were reported by the operating surgeon to have healed. Active bleeding was seen in twenty-eight duodenal ulcers as contrasted with six actively bleeding gastric ulcers. The ratio of active duodenal ulcer to active gastric ulcer is 4 to 1, which is approximately the same for actively bleeding duodenal ulcer to actively bleeding gastric ulcer. Supplemental Operative Procedures. As noted in Table VI, gastrostomy with a 5 cc Number 22 Foley catheter has been employed in 68.2 per cent of patients for gastric decompression. More recently, a considerable group of patients have had no gastric decompression postoperatively without untoward results. Actively bleeding duodenal and gastric ulcers have been managed with suture ligation in twentyeight patients. The technic usually employed is the placement of one or two deeply seated Number 2-O chromic catgut sutures into the ulcer bed for hemostatic control. Gastrotomy has been used infrequently as a separate procedure since the pyloroplasty is usually Signs
and
Symptoms
of Peptic
Pain Obstruction Hemorrhage Acute perforation Previous perforation
Ulcer
adequate for the evaluation of the distal gastric mucosa. Wedge resection of gastric ulcers has been utilized in nine patients, or in approximately one third of patients with gastric ulcer. An additional six patients with gastric ulcer underwent biopsy and frozen section to prove benignancy. Only one duodenal ulcer was suspect and accordingly biopsied. Additional
Operative
Number of Patients
Per cent
TABLE
IV
Variety
Operation
of Operations
Vagotomy and pyloroplosty
Duodenal
Ulcer
Ulcer
25
Anterior gastrojejunostomy
35.0
Vagotomy, subtotal
115
54.0
gastric resection, and Billroth II
.a
Ulcer --__
3
21
Total
Per
Number
cent
4
4
1.9
1
173*
77.2
37
17.5
3
1.5
4
1.9
2
11
Vagotomy, subtotal
74
ii
VII).
Posterior gastro-
gastric resection, and Billroth I
25
147
Stoma1
Vagotomy
78.0
0.4
(Table
(211 Patients)
Gastric
Vagotomy
165
1
Procedures
Splenectomy was performed in eight patients (3.7 per cent) as a direct sequela to operative trauma. In each instance splenic injury occurred during the performance of truncal vagotomy and, with one exception, occurred when a surgical resident was the chief surgeon. As nearly as could be determined, operative morbidity and mortality were unrelated in this series to any of the additional operative procedures performed. Postoperative Complications. A total of fifty-eight complications occurred in 211 patients, as seen in Table VIII. The lethal complications were pulmonary embolus (two patients), myocardial infarction (two patients), and gastrointestinal bleeding (two patients). Wound abscess occurred in twenty-seven patients (12.8 per cent) and was the most common by far of all complications. Operative Mortality. In 211 patients the total operative mortality is 2.7 per cent. (Table IX.) It is noteworthy that all deaths occurred in patients with hemorrhage preoperatively. massive gastrointestinal Nonetheless, four of the six patients were doing satis-
jeiunostomy
(211 Patients) Type
54.0 115 .. ..- ~-__-~~-
Incidence of hemorrhage in 21 1 patients _.____~ * Transfusion of less than five units whole blood.
* 71.5 per centof 211 patients are over fifty years of age.
Preoperative
17
2
directly due to hemorrhage
.-
Per
1
80-89
192
Number of Patients
10-19
Sex
II
Hemorrhage ___~
___~__~~
Age (~4
TABLE
Upper Gastrointestinal Hemorrhage (211 Patients) III ______.__~~ _ .._ _ .~. .._.~~._ _.__~.
3
1
2
1
* Includesten petientr with simultaneous gastric and duodenal The American
UICMS.
Journal
of gUrgeW
-
Peptic TABLE V
Operative
Findings (21 I Patients)
Location of Ulcer
Healed*
Duodenal
34
Gastric Sternal Duodenal and gastric
Additional
TABLE VII
Active
Active
(without
(with
Total
Per
bleeding)
bleeding)
Number
cent
Operative
Ulcer
Procedures (211 Patients)
Total Number
Per cent
Splenectomy
0*
3.7
Appendectomy
a
3.7
10
4.0
Procedure
109
28
161
76.3
Cholecystectomy
26
4
32
15.2
Common duct exploration
a
8
3.7
10
10
4.8
Total
* All
related
3
1.5
29
13.7
to surgical trwmo.
* One or more of the following: stenosis, SCOT,edema, petcchiae.
factorily and experienced no further gastrointestinal bleeding, only to die of either pulmonary embolus or myocardial infarction. Postoperative Signs and Symptoms (Table X). In 205 patients that survived surgery, 7.8 per cent had some variety of dumping syndrome, which was classified as severe in only one patient. We have defined the dumping syndrome as follows: (1) fullness, (2) nausea or vomiting, (3) sweating, (4) palpitations, and (5) the necessity to lie down. These signs and symptoms must make their appearance during or within thirty minutes after a meal. Mild dumping suggests that the patient has one of the five signs and symptoms, whereas moderate signifies more than one. Severe dumping indicates one or more of the signs and symptoms, and that, in addition, the patient must lie down. Diarrhea is always difficult to evaluate, and we have interpreted the term to indicate frequent liquid bowel movements. Occasional diarrhea implies one to three liquid bowel movements daily, without urgency or tenesmus. There are twenty-two patients (10.7 per cent) in this group. Severe diarrhea occurred in six patients (2.9 per cent), and implies three or more liquid stools daily with tenesmus. Fortunately, all six patients state that they began to have normal bowel movements two years after surgery. We have seen no intractable diarrhea in this series. Pain, bloating, and bleeding each has approximately a 4 per cent incidence, with bleeding, of course, the major concern. Postoperative Follow Up. One of the crucial elements in any study is the postoperative follow up, and these data are tabulated in Table XI Of the 205 patients surviving surgery, the current status is known in 96.6 per cent of the postoperative survivors (all but seven). Except as noted in patients undergoing re-
operation, the twenty-nine deaths occurring in the 205 postoperative survivors were unrelated in any way to an exacerbation of peptic ulcer. Almost 50 per cent of the total group of patients have been followed up for more than five years, and thirty-three patients have been followed up for ten to nineteen years. Only 6.4 per cent of these patients have been followed up for less than one year and represent our most current group who are beyond three months in postoperative convalescence. The average age at the time of surgery is 56.1 years, and the longest follow up is a nineteen year evaluation of a patient who is now eightyfive years of age and who underwent vagotomy and gastroenterostomy for severe bleeding in 1949. The following reports summarize Reoperation. cases in which reoperation was performed for any reason related to the initial definitive ulcer operation: CASE 1. The patient (AH), aged thirty-two years, underwent vagotomy and anterior gastrojejunostomy for an active duodenal ulcer in 1950. Nine months later, the patient was re-explored, and partial gastrectomy with Billroth I reconstruction performed. This entailed resection of the gastroenterostomy with jejunojejunostomy for relief of a proximal limb obstruction. This patient did not have a stoma1 ulcer and died nine years postoperatively of myocardial infarction. CASE 2. The patient (DR), aged forty-six, underwent vagotomy and anterior gastrojejunostomy in 1966 for an active ulcer. Six weeks later, the patient was returned to the operating room for revision of an almost totally obstructed gastrojejunostomy. Revision of the gastrojejunosPostoperative
TABLE VIII
Procedure Gastrostomy Suture ligation for bleeding
Operative
Procedures
(211
Patients)
Duodenal
Total
Per
Ulcer
Ulcer
Number
cent
23
121
144
68.2
Per cent 0.5
1
Fever
3
1.4
3 (2 died)
1.4
of unknown
origin bleeding accident
Skin allergy Wound
Gastric
Patients)
Subphrenic abscess
Cerebrovarcular
Supplemental
(211
Number of Patients
We
Gastrointestinal
TABLE VI
Complications
1
0.5
1
0.5
1
sinus
Electrolyte
(immediate)
Myocardial
infarction
0.5 0.5
imbalance
2 (died)
0.9
3 (2 died)
1 .4
Thrombophlebitis
5
2.3
Pulmonary
embolus
4
24
28
13.2
Wound
hernia
3
1 .4
Gostrotomy Wedge resection
2 9
1
3
1.4
Gastric
stasis
7
3.3
9
4.2
Wound
abscess
Biopsy of ulcer
6
1
7
3.3
ulcer
Vol. 119, February
1970
Total
27
12.8
58
27.4
193
Savage
and
McVay
tx
TABLE
Operative
Mortality
(211
CWSf2 Myocardiol
Number
infarction
Pulmonary
emboli
Postoperative
gastrointestinal
bleeding
Total * All deothr
occurred
in patients
TABLE
Patients)
with massive
gastrointertinol
XI
Postoperative
Per cent
Years
2
0.9
Under
2
0.9
1-3
Follow-Up
Period
Number
of
Patients
Patients)
Per
cent
13
1
6.4
58
28.3
2
0.9
3-5
32
15.6
6*
2.7
5-10
69
33.7t
10-15
27
13.1t
bleeding
preoperatively.
6
15-19
has been asympto-
*
2.9t
205
Total
tomy was performed, and the patient matic since re-exploration.
(205
100.0
Currentstoturis known in 96.6per hen+of 205 patients. Included ore who are deceased for causes unrelated to peptic ulcer diseore. 49.7per cent of patients have been followed up from five to nineteen
patients t
3. The patient (EE), aged sixty-nine, underwent vagotomy, pyloroplasty, and suture ligation of a bleeding duodenal ulcer in 1968. Twelve days postoperatively the patient had an anterior gastrojejunostomy for marked outlet obstruction. The patient has done well since re-exploration.
twenty-nine years.
CASE
Reoperation was employed three patients :
for delayed
bleeding
in
CASE 4. The patient (DP), aged sixty, was operated upon in 1964 for upper gastrointestinal bleeding. No explanation for the hemorrhage was found. Vagotomy and pyloroplasty were performed in 1965 for bleeding, but again, no ulcer or other pathology was identified. Reoperation was necessary in 1967 for bleeding, but careful exploration and gastrotomy revealed no abnormality. The patient had bleeding in 1968 after aspirin had been taken for arthritis, and significantly, no further bleeding has occurred since she has been advised to omit any further aspirin ingestion. CASE 5. The patient (ES), aged forty-one, underwent vagotomy, pyloroplasty, and gastrostomy for active duodenal ulcer in 1964. Re-exploration one week postoperatively revealed a tiny arterial bleeder in the gastric wall which was believed to be secondary to gastrostomytube trauma.
The patient (WH), aged sixty-one, was operated upon in 19.58 for a bleeding duodenal ulcer. Vagotomy, pyloroplasty, and gastrostomy were performed; but CASE
TABLE
6.
Postoperative
X
Signs
and
Number
Symptoms of
Patients
(205
Patients)
Per
cent
Dumping 5.4
11
Mild Moderate
4
1.9
Severe
1
0.5
Totol
16
7.8
22
10.7
Diarrhea Occasional Severe
6*
2.9
Intractable
0
0.0
I
28
13.6
Tota
9
4.4
10
4.8
Bleeding
(delayed)
’ All six patients hove normal bowel movements t Iwo patients were w-explored surgically.
194
3.4
7t at two
years
postoperatively
gastrectomy
else-
Four additional patients had melena after a definitive ulcer operation. Three of these patients had had vagotomy and pyloroplasty; and the fourth patient had undergone vagotomy, subtotal gastrectomy, and Billroth I reconstruction. Three patients were found to have gastric cancer: CASE 7. The patient (TH), aged fifty-three, had been operated upon for duodenal ulcer with vagotomy and pyloroplasty in 1965, only to return for reoperation fourteen months later with far advanced gastric carcinoma.
CASE 8. The patient (BN), aged fifty-eight, underwent vagotomy, pyloroplasty, and excision of a gastric ulcer in 1953. Sixteen years later, the patient was found to have an operable gastric carcinoma.
CASE 9. The patient (JA), aged fifty, underwent vagotomy and posterior gastrojejunostomy for recurrent stoma1 ulcer and a gastrojejunocolic fistula in 19.51. The operation included closure of the colonic fistula, and resection and reanastomosis of the jejunum. Approximately fifteen years later, the patient was found to have an inoperable gastric cancer. Peptic Ulcer Recurrence. In Table XII we have cited four patients (1.9 per cent) as having recurrence of ulcer proved by operation. Their cases arc summarized as follows: CASE IO. The patient (CH), aged sixty-two, had vagotomy and pyloroplasty in 1954 for an active duodenal ulcer. He was re-explored elsewhere in 1960 and a gastroenterostomy was performed for a recurrent duodenal ulcer. He is currently asymptomatic. Carotid body resection was performed elsewhere in 1967 for emphysema.
CASE 11. The patient (RH), aged fifty-eight, underwent vagotomy and pyloroplasty with suture ligation of a bleeding duodenal ulcer in 1956 for massive hemorrhage. TABLE
Pain Bloating
in 1963 the patient underwent subtotal where, presumably for a recurrent ulcer.
XII
Peptic
Ulcer
Recurrence Proved Possible Total
Recurrence
(205
Number
of
Patients
Per
cent
4
1.9
6
2.9
10
4.8
(reoperation) (roentgenogrom,
Patients)
history)
The
American
Journal
of Surgery
Peptic
Reoperation in 1964 for massive bleeding revealed a recurrent duodenal ulcer. This patient initially responded, only to die of myocardial infarction on the seventh postoperative day. CASE 12. The patient (WH), aged sixty-one, was operated upon for massive bleeding in 1958. Vagotomy, pyloroplasty, and suture ligation of a bleeding duodenal ulcer were performed. In 1963 a subtotal gastric resection was performed elsewhere, but the operative findings are unknown. Current status is satisfactory. CASE 13. The patient (JM), aged forty-eight, underwent vagotomy, pyloroplasty, and gastrostomy in 1962 for an active duodenal ulcer. In 1968 re-exploration revealed an intact left vagus nerve. After division of the left vagus, an anterior gastrojejunostomy was performed. The patient had an active recurrent duodenal ulcer with a positive preoperative Hollander test.
Six additional patients were placed in the category of possible ulcer recurrence on the basis of pertinent history and x-ray examination. Four of the six patients had an apparent bleeding episode subsequent to definitive ulcer surgery. In no instance was the Hollander test positive, and current evaluation finds them asymptomatic and free of bleeding from eighteen months to nine years. Two additional patients had suggestive ulcer symptoms with compatible gastrointestinal roentgenograms. Negative Hollander tests in both instances added considerable confusion. Nonetheless, current evaluation finds both patients symptom-free. The possible ulcer recurrence rate is 2.9 with 4.8 per cent representing the combined total. Comments
The surgical treatment of peptic ulcer is at its best the inexorable evolution in the application of laboratory research to clinical surgery. Many of the fundamental and far-reaching contributions in vagal and antral physiology support the proposition that the most physiologic operation for duodenal ulcer is vagotomy, antrectomy, and Billroth I reconstruction [3,4]. Counter contentions raised in many quarters [5-71 suggest that morbidity and mortality rates are much lower in these patients undergoing vagotomy and a drainage procedure. For example, vagotomy and drainage have been utilized extensively for patients with massive bleeding by Farris and Smith [8] with a high degree of success, and in the present series with a mortality of 0.9 per cent. Recurrent ulceration is of crucial concern, and our experience coincides with that of others who suggest that this complication is seen predominately in patients with retained vagi or when the drainage procedure has been inadequate. Nonetheless, these operative problems have been of a relatively minor order of importance in this study, as the proved recurrence rate by re-exploration was 1.9 per cent. Vol. 119,
February
1970
Ulcer
Finally, it would appear in this and other studies that with increasing experience with vagotomy and pyloroplasty, this operation is likely to be even more rewarding in terms of morbidity, mortality, and recurrent ulceration. Vagotomy with pyloroplasty remains our procedure of choice for either duodenal or gastric ulcer [9,10], and any modifications such as selective vagotomy [II] or antral exclusion are yet to be proved with time. All varieties of subtotal gastric resection have been employed only when vagotomy and drainage have failed, or when the operation was widely employed as initial surgical therapy, as it was more than a decade ago. Summary 1. 54.0 per cent of 211 patients with peptic ulcer had either acute or chronic gastrointestinal hemorrhage preoperatively. 49.0 per cent of the patients with preoperative bleeding had massive bleeding and required five or more units of whole blood. 2. 94.7 per cent of 211 consecutive patients with peptic ulcer underwent vagotomy with a drainage procedure as definitive therapy. 3. Six patients (2.7 per cent) died postoperatively, although in only two (0.9 per cent) patients could death be classified due to operative failure since fatal hemorrhage recurred. 4. The current status is known in 96.6 per cent (198) of 205 patients. 49.7 per cent of 205 postoperative patients have been followed up from five to nineteen years. The longest follow-up period is in excess of nineteen years and concerns a patient who underwent vagotomy and gastroenterostomy for severe bleeding in 1949. 5. The proved peptic ulcer recurrence rate is 1.9 per cent (four patients) of 205 patients. The possible recurrence is 2.9 per cent (six patients) and the combined total is 4.8 per cent. There was no recurrence of gastric ulcer in twentyseven patients or in ten additional patients with simultaneous gastric and duodenal ulcer. These data strongly support vagotomy with a drainage procedure for the following conditions: (1) acute and chronic duodenal ulcer, including massive hemorrhage; (2) benign gastric ulcer; (3) simultaneous duodenal and gastric ulcer. References
Harkins
HN, Stavney LS, Griffith CA, Savage LE, Kato T, and Nyhus LM: Selective gastric vagotomy. Ann Surg 158: 448, 1963. 2. Weinberg JA, Stempien SJ, Movius HJ, and Dagrad AE: Vagotomy and pyloroplasty in the treatment of duodenal ulcer. Amer J Surg 92: 202, 1956. 3. Edwards LW, and Herrington JL, Jr. Efficacy of 40-per cent gastrectomy combined with vagotomy for duodenal ulcer. Surgery 41: 2, 1957. 4. Savage LE, Stavney LS, Harkins HN, Nyhus LM: Com1.
195
Savage
5. 6. 7.
8.
9.
10.
11.
and McVay
parison of the combined operation and Billroth I gastrectomy in the treatment of chronic duodenal ulcer. Amer J Surg 107: 283, 1964. Dragstedt LR: Peptic ulcer. Amer J Surg 117: 143, i969. Kraft RO, Fry WS, and Ransom RH: Selective gastric vagotomy. Arch Surg 85: 687, 1962. Hoerr SO: Evaluation of vagotomy with gastroenterostomy performed for chronic duodenal ulcer. Report based on five-year follow-up of 145 patients. Surgery 38: 149, 1955. Farris JM and Smith GK: Appraisal of long-term results of vagotomy and pyloroplasty in 100 patients with bleeding duodenal ulcer. Ann Surg 166: 328, 1967. Giles GR, Mason MC, and Clark CG: Vagotomy and acid secretion in patients with gastric ulcer. Lancet 2: 306, 1968. McNeil1 AD, McAdam WAF, and Hutchison JSF: Vagotomy and drainage in the treatment of gastric ulcer. Surg Gynec & Obst 128: 91, 1969. Smith GK and Farris JM: Reappraisal of the long-term effects of selective vagotomy. Amer J Surg 117: 222, 1968.
Discussion STANLEY 0 HOERR (Cleveland, Ohio) : I would like to congratulate Drs Savage and McVay not only for a fine continuing follow-up study which will become more and more valuable as time goes on, but also on their excellent results. By coincidence I started a continuing follow-up study in 1950 of my own, and am compiling the results as I go along. Although I also regard vagotomy and pyloroplasty as the “procedure of choice,” in roughly 30 per cent of our last hundred patients we performed vagotomy and gastroenterostomy (usually for a mass in connection with the ulcer or if there is a lot of scarring), and in 10 per cent we performed vagotomy and a gastric resection. Like the authors, I have been using vagotomy and pyloroplasty in selected patients with gastric ulcer, when malignancy can be essentially conclusively ruled out. In conventional statistics it is difficult to account for episodes of what one might call digestive “unhappiness:” so in my own studies I have been using a new classification when there is a temporary failure in a patient who then becomes asymptomatic. We had one patient who nineteen years ago, had vagotomy and gastroenterostomy and who had a single episode of bleeding about ten years ago, lasting three or four days and not requiring hospitalization: he would fall into such a classification. Actually, he regards himself as having a very good surgical result! Comparing statistics between different patient populations and between different surgeons is very tricky because so much subjective evaluation enters into it. I was interested to find that the late results in three operations I performed through the years are essentially the same. There is a hard core of about 10 per cent of patients who are not pleased with results no matter what treatment is used. If one accepts the fact that with drainage procedures it will be occasionally necessary to per-
196
form secondary operations for recurrent ulcers (and in m) own experience this has come out at about 10 per cent). the end results are just as good and the digestive woes occurring after gastric resection are avoided in the 90 per cent who do not require a resection. LOUIS T PALUMRO (Des Moines, Iowa): I would like to compliment Dr Savage and Dr McVay on their excellent study of pyloroplasty-vagotomy for duodenal and benign gastric ulcer: their over-all results are excellent, and both the morbidity and mortality are low considering rhe inclusion of patients with massive hemorrhage. There has been a great evolution in surgery in this country during the past twenty years with the development and adoption of four or five very conservative operations for the control of this condition. These procedures have been developed on sound anatomic and physiologic principles to control the primary gastric secretory mechanisms responsible for hyperacidity in the pathogenesis of an ulcer. Since 1953, in our institution we still favor our procedure of distal antrectomy (25 per cent or less resection of distal portion of stomach) with a bilateral vagus resection, Billroth II, or anterior Hofmeister or Polya procedure. We now have performed this procedure in more than 600 patients. I cannot compare our results with those of Dr McVay since our experiences with other conservative procedures are less in number and also because of some degree of selectivity of our cases. During the past six or seven years we have performed pyloroplasty-vagotomy in eighty-three patients and gastroenterostomy-vagotomy in forty-five. Doctor Savage made an important point concerning the number of patients in the older age group. This compounds the problem of surgery because of the higher incidence of morbidity and mortality due to existing intercurrent diseases. During the past year, for duodenal ulcer we have performed distal antrectomy-vagotomy in 75 per cent of the patients, pyloroplasty in 15 to 20 per cent, and gastroenterostomy-vagotomy in 5 to 10 per cent. In benign gastric ulcer we have come a complete circle. We have worked on the basis of the observations of Dr Dragstedt, Sr. that the pathogenesis of this lesion is due to hyperfunctioning of the antrum from delayed gastric emptying and atonicity of the stomach. We have tried the various conservative procedures advocated by others, but have now returned to performing distal antrectomy-vagotomy with a Billroth II operation for benign ulcers. If the ulcer is located in the portion of the stomach to be resected, it is removed; otherwise, if it appears to he benign and multiple frozen section studies reveal no evidence of malignancy, the ulcer is left in situ (if no complications of ulcer exist at the time). If gastric analysis reveals low acids (below normal) and low total secretory volume, antrectomy is performed; if, however, the acid levels are above normal with an above normal secretory volume, distal antrectomy-vagectomy is performed.
The American Journal of Surgery
Management
of Peptic Ulcer L E SAVAGE, C B McVAY,
In 1949, vagotomy and gastroenterostomy were initially utilized only in the management of patients seriously ill with peptic ulcer. During the subsequent decade, vagotomy with some variety of drainage procedure has been performed with increasing frequency. By 1959, the vast majority of surgical candidates with peptic ulcer were managed with this operation. Thus, for twenty years we have been able to observe and carefully evaluate patients who have been treated with vagotomy and a drainage operation for all of the complications of peptic ulcer. Finally, this operation has been our first-line procedure over many years for both gastric and duodenal ulceration, including most of their acute and chronic variants. Clinical
Data
This series consists of 211 patients having either vagotomy with subtotal gastrectomy or vagotomy with a drainage procedure, and is entirely unselected, with the exception that initially only the dire-risk patient received the latter operation. It is also a consecutive series of patients with vagotomy, exclusive of a few patients who were eliminated from the study because their peptic ulcer was a part of a much more serious disease complex, such as pancreatic carcinoma or gastric cancer. The operative approach was identical in each case. A transverse upper abdominal incision was employed, and after the abdominal viscera were thoroughly inspected, a Penrose drain was placed about the abdominal esophagus for gentle traction. The triangular ligament of the left lobe of the liver was frequently incised for easier mobilization of the vagi. The celiac division of the right vagus and the hepatic branch of the left vagus, as illustrated by Harkins et al [I], were extremely useful landmarks in the location and performance of a total truncal vagotomy. Silver clips were placed and 3 to 4 cm of the vagi were resected, Circumferential dissection of the abdominal esophagus was then carried out to obviate the possibility of retained vagal fibers. The pyloroplasty, with rare exception, was of the Heineke-Mikulicz type with a onelayer silk closure employed most frequently [2]. A From the Department of Surgery, University of South Dakota School of Medicine. and the Yankton Clinic, Yankton. South Dakota. Presented at the Tenth Annual Meetina of the Society for Surnerv of the Alimentary Tract, New York, New York, July 12 and 13, 1969.
Vol. 119, February 1970
MD, MD,
Yankton, Yankton,
South South
Dakota Dakota
gastroenterostomy,
if utilized, was usually anterior and isoperistaltic. In either drainage procedure we hoped to achieve a 2 to 4 cm stoma. Frequently, a Stamm gastrostomy was employed, using a 5 cc Number 22 Foley catheter. A musculofascial peritoneal closure in one layer with stainless steel sutures was customary, and the subcutaneous tissue and skin were closed with fine silk. The patients were usually started on liquids by the third postoperative day and were dismissed between the sixth and tenth day after surgery. Age and Sex. As noted in Table I, the majority of the 211 patients (71.5 per cent) were over fifty years of age when they were operated upon. The ratio of male to female patients was about 3 to 1. Preoperative Signs and Symptoms. Table II points out the usual high frequency of pain in patients with peptic ulcer, but the more striking fact is that 54 per cent of these patients had active bleeding or had documentation of previous bleeding when admitted to the hospital for surgery. Only one patient with acute perforation was treated with a definitive vagotomy procedure initially. It has been usual for a patient with previous perforation to undergo a definitive operation, and twenty-five such patients are included in this series. Upper Gastrointestinal Hemorrhage. A tabular summary of patients with upper gastrointestinal hemorrhage is noted in Table III. Hemorrhage was graded on the basis of massive (transfusion of more than five units of whole blood), moderate (less than five units of whole blood), or a positive history with or without previous transfusion. Of 211 patients, 115 presented with upper gastrointestinal hemorrhage (54.0 per cent). The serious nature of this problem is noted in the 49 per cent who received five or more units of whole blood prior to surgery. The mortality in 115 patients with upper gastrointestinal hemorrhage was 1.7 per cent. Variety of Operations. In Table IV it is noted that the great majority of patients (77.2 per cent) underwent vagotomy and pyloroplasty. Vagotomy alone was utilized four times in the management of recurrent stoma1 ulcer. Vagotomy and gastrojejunostomy were utilized thirty-seven times and continue to be a most useful alternative in a patient with a severely indurated duodenum in whom pyloroplasty may be hazardous. Any combination of vagotomy and subtotal gastric re191
Savage and McVay TABLE
Age
I
and
Sax of 211
Data
Patients
Number of Patients
TABLE Per cent
____
~_. _.-. .~~~-.
._._
Positive history
39
34.0
0.4
Moderate*
20
17 0
20-29
5
2.4
Massive t
56
49 0
30-39
13
6.2
40-49
41
19.5
50-59
69
32.7*
60-69
51
24.2*
70-79
27
12.7*
4
1.9*
Mortality
Male Female
160
75.8
51
24.2
t Transfusion of more than five units whole blood.
section as primary surgical treatment for peptic ulcer has not been performed for more than a decade at the Yankton Clinic. Simultaneous duodenal and gastric ulcers were seen in ten patients who were all treated with vagotomy, pyloroplasty, and not infrequently with excision of the gastric ulcer. It is noteworthy that most benign gastric ulcers were managed with vagotomy and pyloroplasty. Operative Findings. A documentation of the operative findings is presented in Table V. Duodenal ulcer accounted for 76.3 per cent of the pathologic disorders in this series; thirty-four of these 161 duodenal ulcers were reported by the operating surgeon to have healed. Active bleeding was seen in twenty-eight duodenal ulcers as contrasted with six actively bleeding gastric ulcers. The ratio of active duodenal ulcer to active gastric ulcer is 4 to 1, which is approximately the same for actively bleeding duodenal ulcer to actively bleeding gastric ulcer. Supplemental Operative Procedures. As noted in Table VI, gastrostomy with a 5 cc Number 22 Foley catheter has been employed in 68.2 per cent of patients for gastric decompression. More recently, a considerable group of patients have had no gastric decompression postoperatively without untoward results. Actively bleeding duodenal and gastric ulcers have been managed with suture ligation in twentyeight patients. The technic usually employed is the placement of one or two deeply seated Number 2-O chromic catgut sutures into the ulcer bed for hemostatic control. Gastrotomy has been used infrequently as a separate procedure since the pyloroplasty is usually Signs
and
Symptoms
of Peptic
Pain Obstruction Hemorrhage Acute perforation Previous perforation
Ulcer
adequate for the evaluation of the distal gastric mucosa. Wedge resection of gastric ulcers has been utilized in nine patients, or in approximately one third of patients with gastric ulcer. An additional six patients with gastric ulcer underwent biopsy and frozen section to prove benignancy. Only one duodenal ulcer was suspect and accordingly biopsied. Additional
Operative
Number of Patients
Per cent
TABLE
IV
Variety
Operation
of Operations
Vagotomy and pyloroplosty
Duodenal
Ulcer
Ulcer
25
Anterior gastrojejunostomy
35.0
Vagotomy, subtotal
115
54.0
gastric resection, and Billroth II
.a
Ulcer --__
3
21
Total
Per
Number
cent
4
4
1.9
1
173*
77.2
37
17.5
3
1.5
4
1.9
2
11
Vagotomy, subtotal
74
ii
VII).
Posterior gastro-
gastric resection, and Billroth I
25
147
Stoma1
Vagotomy
78.0
0.4
(Table
(211 Patients)
Gastric
Vagotomy
165
1
Procedures
Splenectomy was performed in eight patients (3.7 per cent) as a direct sequela to operative trauma. In each instance splenic injury occurred during the performance of truncal vagotomy and, with one exception, occurred when a surgical resident was the chief surgeon. As nearly as could be determined, operative morbidity and mortality were unrelated in this series to any of the additional operative procedures performed. Postoperative Complications. A total of fifty-eight complications occurred in 211 patients, as seen in Table VIII. The lethal complications were pulmonary embolus (two patients), myocardial infarction (two patients), and gastrointestinal bleeding (two patients). Wound abscess occurred in twenty-seven patients (12.8 per cent) and was the most common by far of all complications. Operative Mortality. In 211 patients the total operative mortality is 2.7 per cent. (Table IX.) It is noteworthy that all deaths occurred in patients with hemorrhage preoperatively. massive gastrointestinal Nonetheless, four of the six patients were doing satis-
jeiunostomy
(211 Patients) Type
54.0 115 .. ..- ~-__-~~-
Incidence of hemorrhage in 21 1 patients _.____~ * Transfusion of less than five units whole blood.
* 71.5 per centof 211 patients are over fifty years of age.
Preoperative
17
2
directly due to hemorrhage
.-
Per
1
80-89
192
Number of Patients
10-19
Sex
II
Hemorrhage ___~
___~__~~
Age (~4
TABLE
Upper Gastrointestinal Hemorrhage (211 Patients) III ______.__~~ _ .._ _ .~. .._.~~._ _.__~.
3
1
2
1
* Includesten petientr with simultaneous gastric and duodenal The American
UICMS.
Journal
of gUrgeW
-
Peptic TABLE V
Operative
Findings (21 I Patients)
Location of Ulcer
Healed*
Duodenal
34
Gastric Sternal Duodenal and gastric
Additional
TABLE VII
Active
Active
(without
(with
Total
Per
bleeding)
bleeding)
Number
cent
Operative
Ulcer
Procedures (211 Patients)
Total Number
Per cent
Splenectomy
0*
3.7
Appendectomy
a
3.7
10
4.0
Procedure
109
28
161
76.3
Cholecystectomy
26
4
32
15.2
Common duct exploration
a
8
3.7
10
10
4.8
Total
* All
related
3
1.5
29
13.7
to surgical trwmo.
* One or more of the following: stenosis, SCOT,edema, petcchiae.
factorily and experienced no further gastrointestinal bleeding, only to die of either pulmonary embolus or myocardial infarction. Postoperative Signs and Symptoms (Table X). In 205 patients that survived surgery, 7.8 per cent had some variety of dumping syndrome, which was classified as severe in only one patient. We have defined the dumping syndrome as follows: (1) fullness, (2) nausea or vomiting, (3) sweating, (4) palpitations, and (5) the necessity to lie down. These signs and symptoms must make their appearance during or within thirty minutes after a meal. Mild dumping suggests that the patient has one of the five signs and symptoms, whereas moderate signifies more than one. Severe dumping indicates one or more of the signs and symptoms, and that, in addition, the patient must lie down. Diarrhea is always difficult to evaluate, and we have interpreted the term to indicate frequent liquid bowel movements. Occasional diarrhea implies one to three liquid bowel movements daily, without urgency or tenesmus. There are twenty-two patients (10.7 per cent) in this group. Severe diarrhea occurred in six patients (2.9 per cent), and implies three or more liquid stools daily with tenesmus. Fortunately, all six patients state that they began to have normal bowel movements two years after surgery. We have seen no intractable diarrhea in this series. Pain, bloating, and bleeding each has approximately a 4 per cent incidence, with bleeding, of course, the major concern. Postoperative Follow Up. One of the crucial elements in any study is the postoperative follow up, and these data are tabulated in Table XI Of the 205 patients surviving surgery, the current status is known in 96.6 per cent of the postoperative survivors (all but seven). Except as noted in patients undergoing re-
operation, the twenty-nine deaths occurring in the 205 postoperative survivors were unrelated in any way to an exacerbation of peptic ulcer. Almost 50 per cent of the total group of patients have been followed up for more than five years, and thirty-three patients have been followed up for ten to nineteen years. Only 6.4 per cent of these patients have been followed up for less than one year and represent our most current group who are beyond three months in postoperative convalescence. The average age at the time of surgery is 56.1 years, and the longest follow up is a nineteen year evaluation of a patient who is now eightyfive years of age and who underwent vagotomy and gastroenterostomy for severe bleeding in 1949. The following reports summarize Reoperation. cases in which reoperation was performed for any reason related to the initial definitive ulcer operation: CASE 1. The patient (AH), aged thirty-two years, underwent vagotomy and anterior gastrojejunostomy for an active duodenal ulcer in 1950. Nine months later, the patient was re-explored, and partial gastrectomy with Billroth I reconstruction performed. This entailed resection of the gastroenterostomy with jejunojejunostomy for relief of a proximal limb obstruction. This patient did not have a stoma1 ulcer and died nine years postoperatively of myocardial infarction. CASE 2. The patient (DR), aged forty-six, underwent vagotomy and anterior gastrojejunostomy in 1966 for an active ulcer. Six weeks later, the patient was returned to the operating room for revision of an almost totally obstructed gastrojejunostomy. Revision of the gastrojejunosPostoperative
TABLE VIII
Procedure Gastrostomy Suture ligation for bleeding
Operative
Procedures
(211
Patients)
Duodenal
Total
Per
Ulcer
Ulcer
Number
cent
23
121
144
68.2
Per cent 0.5
1
Fever
3
1.4
3 (2 died)
1.4
of unknown
origin bleeding accident
Skin allergy Wound
Gastric
Patients)
Subphrenic abscess
Cerebrovarcular
Supplemental
(211
Number of Patients
We
Gastrointestinal
TABLE VI
Complications
1
0.5
1
0.5
1
sinus
Electrolyte
(immediate)
Myocardial
infarction
0.5 0.5
imbalance
2 (died)
0.9
3 (2 died)
1 .4
Thrombophlebitis
5
2.3
Pulmonary
embolus
4
24
28
13.2
Wound
hernia
3
1 .4
Gostrotomy Wedge resection
2 9
1
3
1.4
Gastric
stasis
7
3.3
9
4.2
Wound
abscess
Biopsy of ulcer
6
1
7
3.3
ulcer
Vol. 119, February
1970
Total
27
12.8
58
27.4
193
Savage
and
McVay
tx
TABLE
Operative
Mortality
(211
CWSf2 Myocardiol
Number
infarction
Pulmonary
emboli
Postoperative
gastrointestinal
bleeding
Total * All deothr
occurred
in patients
TABLE
Patients)
with massive
gastrointertinol
XI
Postoperative
Per cent
Years
2
0.9
Under
2
0.9
1-3
Follow-Up
Period
Number
of
Patients
Patients)
Per
cent
13
1
6.4
58
28.3
2
0.9
3-5
32
15.6
6*
2.7
5-10
69
33.7t
10-15
27
13.1t
bleeding
preoperatively.
6
15-19
has been asympto-
*
2.9t
205
Total
tomy was performed, and the patient matic since re-exploration.
(205
100.0
Currentstoturis known in 96.6per hen+of 205 patients. Included ore who are deceased for causes unrelated to peptic ulcer diseore. 49.7per cent of patients have been followed up from five to nineteen
patients t
3. The patient (EE), aged sixty-nine, underwent vagotomy, pyloroplasty, and suture ligation of a bleeding duodenal ulcer in 1968. Twelve days postoperatively the patient had an anterior gastrojejunostomy for marked outlet obstruction. The patient has done well since re-exploration.
twenty-nine years.
CASE
Reoperation was employed three patients :
for delayed
bleeding
in
CASE 4. The patient (DP), aged sixty, was operated upon in 1964 for upper gastrointestinal bleeding. No explanation for the hemorrhage was found. Vagotomy and pyloroplasty were performed in 1965 for bleeding, but again, no ulcer or other pathology was identified. Reoperation was necessary in 1967 for bleeding, but careful exploration and gastrotomy revealed no abnormality. The patient had bleeding in 1968 after aspirin had been taken for arthritis, and significantly, no further bleeding has occurred since she has been advised to omit any further aspirin ingestion. CASE 5. The patient (ES), aged forty-one, underwent vagotomy, pyloroplasty, and gastrostomy for active duodenal ulcer in 1964. Re-exploration one week postoperatively revealed a tiny arterial bleeder in the gastric wall which was believed to be secondary to gastrostomytube trauma.
The patient (WH), aged sixty-one, was operated upon in 19.58 for a bleeding duodenal ulcer. Vagotomy, pyloroplasty, and gastrostomy were performed; but CASE
TABLE
6.
Postoperative
X
Signs
and
Number
Symptoms of
Patients
(205
Patients)
Per
cent
Dumping 5.4
11
Mild Moderate
4
1.9
Severe
1
0.5
Totol
16
7.8
22
10.7
Diarrhea Occasional Severe
6*
2.9
Intractable
0
0.0
I
28
13.6
Tota
9
4.4
10
4.8
Bleeding
(delayed)
’ All six patients hove normal bowel movements t Iwo patients were w-explored surgically.
194
3.4
7t at two
years
postoperatively
gastrectomy
else-
Four additional patients had melena after a definitive ulcer operation. Three of these patients had had vagotomy and pyloroplasty; and the fourth patient had undergone vagotomy, subtotal gastrectomy, and Billroth I reconstruction. Three patients were found to have gastric cancer: CASE 7. The patient (TH), aged fifty-three, had been operated upon for duodenal ulcer with vagotomy and pyloroplasty in 1965, only to return for reoperation fourteen months later with far advanced gastric carcinoma.
CASE 8. The patient (BN), aged fifty-eight, underwent vagotomy, pyloroplasty, and excision of a gastric ulcer in 1953. Sixteen years later, the patient was found to have an operable gastric carcinoma.
CASE 9. The patient (JA), aged fifty, underwent vagotomy and posterior gastrojejunostomy for recurrent stoma1 ulcer and a gastrojejunocolic fistula in 19.51. The operation included closure of the colonic fistula, and resection and reanastomosis of the jejunum. Approximately fifteen years later, the patient was found to have an inoperable gastric cancer. Peptic Ulcer Recurrence. In Table XII we have cited four patients (1.9 per cent) as having recurrence of ulcer proved by operation. Their cases arc summarized as follows: CASE IO. The patient (CH), aged sixty-two, had vagotomy and pyloroplasty in 1954 for an active duodenal ulcer. He was re-explored elsewhere in 1960 and a gastroenterostomy was performed for a recurrent duodenal ulcer. He is currently asymptomatic. Carotid body resection was performed elsewhere in 1967 for emphysema.
CASE 11. The patient (RH), aged fifty-eight, underwent vagotomy and pyloroplasty with suture ligation of a bleeding duodenal ulcer in 1956 for massive hemorrhage. TABLE
Pain Bloating
in 1963 the patient underwent subtotal where, presumably for a recurrent ulcer.
XII
Peptic
Ulcer
Recurrence Proved Possible Total
Recurrence
(205
Number
of
Patients
Per
cent
4
1.9
6
2.9
10
4.8
(reoperation) (roentgenogrom,
Patients)
history)
The
American
Journal
of Surgery
Peptic
Reoperation in 1964 for massive bleeding revealed a recurrent duodenal ulcer. This patient initially responded, only to die of myocardial infarction on the seventh postoperative day. CASE 12. The patient (WH), aged sixty-one, was operated upon for massive bleeding in 1958. Vagotomy, pyloroplasty, and suture ligation of a bleeding duodenal ulcer were performed. In 1963 a subtotal gastric resection was performed elsewhere, but the operative findings are unknown. Current status is satisfactory. CASE 13. The patient (JM), aged forty-eight, underwent vagotomy, pyloroplasty, and gastrostomy in 1962 for an active duodenal ulcer. In 1968 re-exploration revealed an intact left vagus nerve. After division of the left vagus, an anterior gastrojejunostomy was performed. The patient had an active recurrent duodenal ulcer with a positive preoperative Hollander test.
Six additional patients were placed in the category of possible ulcer recurrence on the basis of pertinent history and x-ray examination. Four of the six patients had an apparent bleeding episode subsequent to definitive ulcer surgery. In no instance was the Hollander test positive, and current evaluation finds them asymptomatic and free of bleeding from eighteen months to nine years. Two additional patients had suggestive ulcer symptoms with compatible gastrointestinal roentgenograms. Negative Hollander tests in both instances added considerable confusion. Nonetheless, current evaluation finds both patients symptom-free. The possible ulcer recurrence rate is 2.9 with 4.8 per cent representing the combined total. Comments
The surgical treatment of peptic ulcer is at its best the inexorable evolution in the application of laboratory research to clinical surgery. Many of the fundamental and far-reaching contributions in vagal and antral physiology support the proposition that the most physiologic operation for duodenal ulcer is vagotomy, antrectomy, and Billroth I reconstruction [3,4]. Counter contentions raised in many quarters [5-71 suggest that morbidity and mortality rates are much lower in these patients undergoing vagotomy and a drainage procedure. For example, vagotomy and drainage have been utilized extensively for patients with massive bleeding by Farris and Smith [8] with a high degree of success, and in the present series with a mortality of 0.9 per cent. Recurrent ulceration is of crucial concern, and our experience coincides with that of others who suggest that this complication is seen predominately in patients with retained vagi or when the drainage procedure has been inadequate. Nonetheless, these operative problems have been of a relatively minor order of importance in this study, as the proved recurrence rate by re-exploration was 1.9 per cent. Vol. 119,
February
1970
Ulcer
Finally, it would appear in this and other studies that with increasing experience with vagotomy and pyloroplasty, this operation is likely to be even more rewarding in terms of morbidity, mortality, and recurrent ulceration. Vagotomy with pyloroplasty remains our procedure of choice for either duodenal or gastric ulcer [9,10], and any modifications such as selective vagotomy [II] or antral exclusion are yet to be proved with time. All varieties of subtotal gastric resection have been employed only when vagotomy and drainage have failed, or when the operation was widely employed as initial surgical therapy, as it was more than a decade ago. Summary 1. 54.0 per cent of 211 patients with peptic ulcer had either acute or chronic gastrointestinal hemorrhage preoperatively. 49.0 per cent of the patients with preoperative bleeding had massive bleeding and required five or more units of whole blood. 2. 94.7 per cent of 211 consecutive patients with peptic ulcer underwent vagotomy with a drainage procedure as definitive therapy. 3. Six patients (2.7 per cent) died postoperatively, although in only two (0.9 per cent) patients could death be classified due to operative failure since fatal hemorrhage recurred. 4. The current status is known in 96.6 per cent (198) of 205 patients. 49.7 per cent of 205 postoperative patients have been followed up from five to nineteen years. The longest follow-up period is in excess of nineteen years and concerns a patient who underwent vagotomy and gastroenterostomy for severe bleeding in 1949. 5. The proved peptic ulcer recurrence rate is 1.9 per cent (four patients) of 205 patients. The possible recurrence is 2.9 per cent (six patients) and the combined total is 4.8 per cent. There was no recurrence of gastric ulcer in twentyseven patients or in ten additional patients with simultaneous gastric and duodenal ulcer. These data strongly support vagotomy with a drainage procedure for the following conditions: (1) acute and chronic duodenal ulcer, including massive hemorrhage; (2) benign gastric ulcer; (3) simultaneous duodenal and gastric ulcer. References
Harkins
HN, Stavney LS, Griffith CA, Savage LE, Kato T, and Nyhus LM: Selective gastric vagotomy. Ann Surg 158: 448, 1963. 2. Weinberg JA, Stempien SJ, Movius HJ, and Dagrad AE: Vagotomy and pyloroplasty in the treatment of duodenal ulcer. Amer J Surg 92: 202, 1956. 3. Edwards LW, and Herrington JL, Jr. Efficacy of 40-per cent gastrectomy combined with vagotomy for duodenal ulcer. Surgery 41: 2, 1957. 4. Savage LE, Stavney LS, Harkins HN, Nyhus LM: Com1.
195
Savage
5. 6. 7.
8.
9.
10.
11.
and McVay
parison of the combined operation and Billroth I gastrectomy in the treatment of chronic duodenal ulcer. Amer J Surg 107: 283, 1964. Dragstedt LR: Peptic ulcer. Amer J Surg 117: 143, i969. Kraft RO, Fry WS, and Ransom RH: Selective gastric vagotomy. Arch Surg 85: 687, 1962. Hoerr SO: Evaluation of vagotomy with gastroenterostomy performed for chronic duodenal ulcer. Report based on five-year follow-up of 145 patients. Surgery 38: 149, 1955. Farris JM and Smith GK: Appraisal of long-term results of vagotomy and pyloroplasty in 100 patients with bleeding duodenal ulcer. Ann Surg 166: 328, 1967. Giles GR, Mason MC, and Clark CG: Vagotomy and acid secretion in patients with gastric ulcer. Lancet 2: 306, 1968. McNeil1 AD, McAdam WAF, and Hutchison JSF: Vagotomy and drainage in the treatment of gastric ulcer. Surg Gynec & Obst 128: 91, 1969. Smith GK and Farris JM: Reappraisal of the long-term effects of selective vagotomy. Amer J Surg 117: 222, 1968.
Discussion STANLEY 0 HOERR (Cleveland, Ohio) : I would like to congratulate Drs Savage and McVay not only for a fine continuing follow-up study which will become more and more valuable as time goes on, but also on their excellent results. By coincidence I started a continuing follow-up study in 1950 of my own, and am compiling the results as I go along. Although I also regard vagotomy and pyloroplasty as the “procedure of choice,” in roughly 30 per cent of our last hundred patients we performed vagotomy and gastroenterostomy (usually for a mass in connection with the ulcer or if there is a lot of scarring), and in 10 per cent we performed vagotomy and a gastric resection. Like the authors, I have been using vagotomy and pyloroplasty in selected patients with gastric ulcer, when malignancy can be essentially conclusively ruled out. In conventional statistics it is difficult to account for episodes of what one might call digestive “unhappiness:” so in my own studies I have been using a new classification when there is a temporary failure in a patient who then becomes asymptomatic. We had one patient who nineteen years ago, had vagotomy and gastroenterostomy and who had a single episode of bleeding about ten years ago, lasting three or four days and not requiring hospitalization: he would fall into such a classification. Actually, he regards himself as having a very good surgical result! Comparing statistics between different patient populations and between different surgeons is very tricky because so much subjective evaluation enters into it. I was interested to find that the late results in three operations I performed through the years are essentially the same. There is a hard core of about 10 per cent of patients who are not pleased with results no matter what treatment is used. If one accepts the fact that with drainage procedures it will be occasionally necessary to per-
196
form secondary operations for recurrent ulcers (and in m) own experience this has come out at about 10 per cent). the end results are just as good and the digestive woes occurring after gastric resection are avoided in the 90 per cent who do not require a resection. LOUIS T PALUMRO (Des Moines, Iowa): I would like to compliment Dr Savage and Dr McVay on their excellent study of pyloroplasty-vagotomy for duodenal and benign gastric ulcer: their over-all results are excellent, and both the morbidity and mortality are low considering rhe inclusion of patients with massive hemorrhage. There has been a great evolution in surgery in this country during the past twenty years with the development and adoption of four or five very conservative operations for the control of this condition. These procedures have been developed on sound anatomic and physiologic principles to control the primary gastric secretory mechanisms responsible for hyperacidity in the pathogenesis of an ulcer. Since 1953, in our institution we still favor our procedure of distal antrectomy (25 per cent or less resection of distal portion of stomach) with a bilateral vagus resection, Billroth II, or anterior Hofmeister or Polya procedure. We now have performed this procedure in more than 600 patients. I cannot compare our results with those of Dr McVay since our experiences with other conservative procedures are less in number and also because of some degree of selectivity of our cases. During the past six or seven years we have performed pyloroplasty-vagotomy in eighty-three patients and gastroenterostomy-vagotomy in forty-five. Doctor Savage made an important point concerning the number of patients in the older age group. This compounds the problem of surgery because of the higher incidence of morbidity and mortality due to existing intercurrent diseases. During the past year, for duodenal ulcer we have performed distal antrectomy-vagotomy in 75 per cent of the patients, pyloroplasty in 15 to 20 per cent, and gastroenterostomy-vagotomy in 5 to 10 per cent. In benign gastric ulcer we have come a complete circle. We have worked on the basis of the observations of Dr Dragstedt, Sr. that the pathogenesis of this lesion is due to hyperfunctioning of the antrum from delayed gastric emptying and atonicity of the stomach. We have tried the various conservative procedures advocated by others, but have now returned to performing distal antrectomy-vagotomy with a Billroth II operation for benign ulcers. If the ulcer is located in the portion of the stomach to be resected, it is removed; otherwise, if it appears to he benign and multiple frozen section studies reveal no evidence of malignancy, the ulcer is left in situ (if no complications of ulcer exist at the time). If gastric analysis reveals low acids (below normal) and low total secretory volume, antrectomy is performed; if, however, the acid levels are above normal with an above normal secretory volume, distal antrectomy-vagectomy is performed.
The American Journal of Surgery