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Antrectomy as treatment of recurrence after vagotomy for duodenal ulcer
Antrectomy as Treatment of Recurrence after Vagotomy for Duodenal Ulcer Per Jess, MD, Copenhagen, Denmark John Christiansen, MD, Copenhagen, Denmark Lars Bo Svendsen, MD, Copenhagen, Denmark
With the purpose of achieving an acceptable cure rate, low mortality, and few sequelae in the surgical treatment of duodenal ulcer, proximal gastric vagotomy without drainage was introduced in 1970 [I,21 and has since gained increasing ground. Results published so far have shown that these expectations on the whole have been met, as it is possible perform proximal gastric vagotomy with practically zero mortality [3-51 and, unlike other types of duodenal ulcer surgery, with minimal risk of severe dumping and diarrhea [6,7], but with recurrence rates up to 10 per cent or more in some series [3,4,8-II]. Definite evaluation of this method cannot be made before the results of surgery for this not inconsiderable number of recurrences are known. The operation most widely used in cases of recurrent ulcer after proximal gastric vagotomy, as well as after other types of vagotomy, is antrectomy (12,131. By studying the results of antrectomy for recurrent ulcer in a group of duodenal ulcer patients treated primarily with some type of vagotomy, that is, truncal vagotomy plus drainage, selective vagotomy plus drainage, or proximal gastric vagotomy, it will at the present time be possible to get an impression of the final outcome of proximal gastric vagotomy as treatment of duodenal ulcer. Material and Methods In the period 1966-1973, sixty-eight patients (55 men and 13 women) underwent antrectomy for recurrent ulcer after primary treatment of duodenal ulcer with truncal vagotomy plus pyloroplasty (45) or gast,rojejunostomy (4), From Departmentof SurgeryA,
Bispebjerg Hospital. Copenhagen, Denmark. Reprint requests should be addressed to John Christiansen. MD, Department of Surgery D. Glostrup Hospital, DK-2600, Glostrup. Copenhagen, Denmark.
336
selective vagotomy plus pyloroplasty (15), or proximal gastric vagatomy (4). Sixty-four patients were operated on electively, whereas four underwent antrectomy because of hemorrhage. Recurrences included duodenal ulcer (56 patients), prepyloric ulcer (8), and gastrojejunal ulcer (4). Median age at the time of antrectomy was fifty-five years in men (range, 20 to 77 years) and fifty-four years in women (range, 28 to 62 years). Median time between the primary vagotomy and the antrectomy was twenty months (range, 1 to 85 months). In fifteen patients the antrectomy was combined with truncal vagotomy. Gastrointestinal continuity was restored by Billroth I anastomosis in fifty-one patients and by Billroth II anastomosis in seventeen. Seven patients died during the follow-up period. A seventy-seven year old man died from cardiorespiratory insufficiency six days after acute antrectomy for bleeding recurrent ulcer. Six patients died five to eighteen months after the antrectomy. The cause of death could be traced in every case from hospital records and/or death certificates. One patient was dead on admittance to the hospital after hematemesis and melena, and his disease has been classified as recurrence after antrectomy although the diagnosis could not be verified, as autopsy was prohibited by the relatives. In the remaining five patients death had no relation to ulcer disease, and no indications of recurrent ulcer disease were found in hospital or private doctors’ records. One patient had left the country and could not be traced. The remaining sixty patients were reexamined, with a median follow-up of sixty-three months (range, 27 to 120 months). The patients had a personal interview and physical examination by one of us. If any dyspeptic symptoms were present or had occurred since the antrectomy, gastroduodenoscopy and X-ray examination of the stomach and duodenum were performed. One patient who despite persistent severe dyspepsia refused to subject himself to these examinations was listed as having a recurrence. Twenty-four patients had an augmented histamine test performed prior to as well as after the antrectomy.
The American Journal 01 Surgery
Antrectomy
TABLE I
Postoperative Complications After Antrectomy (66*patients)
TABLE II ____.
No. of Patients
1 2 1 4 19 7
Postoperative Gastric Complaints (60 patients)
Visick I Visick II Visick III Visick IV
33 12 7 a
Total
60 (lOO%!
No. of Patients 34 16 3 2
Total
60
TABLE Ill
Antrectomy Peak Acid output (mEq/hour)
(16 patients) Reduction (%)
Antrectomy i- Revagotomy (a patients) Peak Acid output Reduction (mEq/hour) (%)
n
.3
1 1
Postprandial Complaints (60 patients) No. of Patients
Epigastric fullness Mild dumping Severe dumping Diarrhea Periodic vomitina
(55%) (20%) (12%) (13%)
Peak Acid Output and Reduction of Peak Acid Output After Anlrectomy (24 patients)
TABLE V
No complaints Minor postprandial complaints; no dyspepsia Severe postprandial complaints: no dyspepsia Dyspepsia; no postprandial complaints Dyspepsia; minor prandial complaints Dyspepsia; severe postprandial complaints Severe dyspepsia and postprandial complaints. Classified as recurrence
Vagotomy
Clinical Results After Antrectomy (60 patients)
TABLE IV
No. of Patients Thromboembolic complications Acute pancreatitis Intraperitoneal abscess Anastomotic leakage Pulmonary complications Wound infection
After
17 5 4 6 1
96.7 80.3 32.2 100.0 83.9 82.7 97.6 2.2 100.0 64.9 94.7 6.3 99.6 34.6 10.9 74.2
0.6 5.6 13.0 0 3.0 4.8 0.6 17.4 0 6.8 1.0 16.0 0 6.8 21.2 5.0 (6.4 f
1.8)
(66.3 f 9.3)
11.4 4.3 9.2 1.2 0.6 4.4 1.4
49.6 74.3 53.1 87.5 96.7 85.4 96.2
13.8
57.7
(5.8 f
1.5)
(75.1 f 6.8)
Note: Numbers in parentheses indicate mean values f SEM.
Results
There was one postoperative death (see Material and Methods), compared with an operative mortality rate of 1.5 per cent (95 per cent confidence limits, 0.0 to 7.9 per cent). Splenic injury requiring splenectomy occurred in four patients. Postoperative complications are shown in Table I. In two of four patients with anastomotic leakage, reoperation was required. Two patients underwent reresection twenty-two and thirty-six months later because of relative stenosis and delayed gastric emptying. Recurrent ulcer was not demonstrated in these two patients either prior to or during the operation. Two patients (2.9 per cent; 95 per cent confidence limits, 0.4 to 10.2 per cent) were classified as having recurrent ulcer. One had dyspepsia as before the antrectomy but refused further examinations, and one died from upper gastrointestinal hemorrhage (see previous section).
Valmw~lR7
March
1979
Of the remaining patients reexamined, twenty-five had some degree of dyspepsia and/or postcibal symptoms. (Tables II and III.) The overall clinical status at follow-up according to the Visick grading is shown in Table IV. Histamine-stimulated acid secretion was studied before and after antrectomy in twenty-four patients. (Table V.) No significant difference in postoperative peak acid output or reduction of peak acid output could be demonstrated between patients with antrectomy and patients with antrectomy plus vagotomy (p > 0.10). Furthermore, no correlation could be demonstrated between persisting dyspepsia and postoperative peak acid output or reduction of peak acid output. Comments
Combined vagotomy-antrectomy seems to be the most effective treatment of duodenal ulcer, since recurrence rates are of the order of magnitude of 1
3.79
Jess, Christiansen,
and Svendsen
per cent even after long-term follow-up [7,14-181. This operation does however carry a mortality of up to 1 per cent and a frequency of postoperat.ive gastric complaints such as dumping and diarrhea of 10 to 25 per cent [7,14,15,17]. Truncal vagotomy plus drainage and selective vagotomy plus drainage carry a lower mortality [19,201 but almost the same rate of gastric complaints atid in most series ,a definitely lower cure rate [21-241. Proximal gastric vagotomy was introduced to reduce the frequency of postoperative gastric complaints, as these were supposed to result from the bypass or mutilation of the pyloroantral region which regulates gastric emptying [25]. Higher cure rates than after other types of vagotomy could not be expected on theoretical grounds, especially not compared with selective vagotomy plus drainage, as denervation of the fundic gland area is achieved in the same way. However, a lower mortality possibly could be expected since no drainage procedure is performed. With respect to gastric complaints, results have been according to expectations, as dumping and diarrhea have been reported in only 0.4 to 5 per cent of patients and usually in a mild degree [3,7,8,Il]. Mortality has been low, as in collected series of more than 5,000 proximal gastric vagotomies, which showed a mortality of only 0.3 per cent [12]. Recurrence rates vary, but in some series with a reasonably long follow-up, are rather high (10 to 22 per cent) [3,9-111. The final evaluation of surgical treatment for duodenal ulcer implies knowledge of the results of treatment of the recurrences. In a series of 260 patients with duodenal or prepyloric ulcer treated with proximal gastric vagotomy in our department and followed up for one to four years, thirty-one recurrences (12 per cent) occurred [3]. Antrectomy in these thirty-one patients should result in 0 to 3 recurrences compared with a “final” recurrence rate of 0 to 1.2 per cent (95 per cent confidence limits). No deaths occurred after proximal gastric vagotomy, but after antrectomy in thirty-one patients, a “final” surgical mortality of 0.1 to 2.4 per cent would result. Eight patients were classified as failures after the antrectomy (Visick IV), compared with a final Visick IV rate of 3 percent (range 0 to 6 per cent). If these figures are compared with the results of long-term follow-up after vagotomy-antrectomy [16-181, the “final” cure rate and the mortality after proximal gastric vagotomy will be the same, whereas the number of failures will be a little higher after vagotomy-antrectomy primarily because of a higher frequency of dumping and diarrhea.
340
These calculations should of course be applied with some caution and may be difficult to apply when choosing a treatment in the individual patient. Factors such as the patient’s general physical condition and the surgeon’s technical skill have not been (and could not be) taken into consideration in these calculations but are of obvious importance. The present study once more emphasizes the importance of continued search for preoperative methods to evaluate patients especially prone to postgastrectomy symptoms such as dumping and diarrhea because such patients, according to current knowledge, should be treated with proximal gastric vagotomy, whereas vagotomy-antrectomy probably would offer an advantage for patients not predisposed to these complications. Summarv
Sixty-eight patients antrectomized for recurrent ulcer after different types of vagotomy were reexamined two to ten years after the operation. Mortality after antrectomy for recurrent ulcer was 1.5 per cent (95 per cent confidence limits, 0.0 to 7.9 per cent), the recurrence rate 2.9 per cent (0.4 to 10.2 per cent), and total failure rate (Visick IV) 13.0 per cent (0.4 to 25.6 per cent). If these figures are applied to a series of 260 proximal gastric vagotomies recently reported from our department and compared with data from series of vagotomy-antrectomy as primary treatment of duodenal ulcer, the final surgical mortality and cure rate will be equal, whereas the final failure rate (Visick IV) probably would be less after proximal gastrid vagotomy because of a lower frequency of dumping and diarrhea. References 1. Amdrup E, Jensen H-E: Selective vagotomy of the parietal cell mass preserving innervation of the undrained antrum. Gastroenterology 59: 522, 1970. 2. Johnston D, Wilkinson AR: Highly selective vagotomy without a drainage procedure in treatment of duodenal ulcer. 8r J Surg 57: 269, 1976. 3. Holst-Christensen J, Hansen OH, Pedersen T, Kronborg 0: Recurrent ulcer after proximal gastric vagotomy for duodenal and pre-pyloric ulcer. Br J Surg 64: 42, 1977. 4. Johnston D: Operative mortality and postoperative morbidity of highly selective vagotomy. Br Med J 4: 545. 1975. 5. Jordan PH Jr: Parietal cell vagotomy without drainage for treatment of duodenal ulcer. Arch Surg 111: 370, 1976. 6. Jordan PH Jr: Current status of parietal celivagotomy. Ann Surg 164: 659, 1976. 7. Sawyers JL. Herrington JL Jr, Burney DP: Proximal gastric vagotomy compared with vagotomy and antrectomy and selective gastric vagotomy and pyloroplasty. Ann Surg 186: 510. 1977. 8. Amdrup E, Jensen H-E, Johnston D. Walker BE, Goligher JC: Clinical results of parietal cell vagotomy two to four years after operation. Ann Surg 180: 279. 1974. 9. Jensen H-E: Personal communication in Jordan PH: Current
The American Journal of Surgery
Antrectomy
10.
11.
12.
13. 14.
15.
16.
status of parietal cell vagotomy. Ann Surg 184: 659, 1976. Kennedy T, Johnston, GW, Malrae KD. Spencer EFA: Proximal gastric vagotomy: interim results of a randomized controlled trial. f3r MedJ 2: 307, 1975. Kronborg 0. Madsen P: A controlled randomized trial of highly selective vagotomy versus selective vagotomy and pyloroplasty in the treatment of duodenal ulcer. Gut 16: 268, 1975. Kronborg 0: A follow-up of patients operated upon for recurrence after vagotomy and drainage for duodenal ulcer. Stand J Gastroenterol8: 123, 1973. Mead PH: Experience with pyloroplasty and vagotomy. Am J Surg 114: 910, 1967. Edwards LW, Edwards WH, Sawyers JL, Gobbel HW, Herrington JL. Scott HW: The suraical treatment of duodenal ulcer bv vagotomy and antral-resection. Am J Surg 105: 352, 1963. Goligher JC, Pulvertaft CN, Watkinson G: Controlled trial of vagotomy and gastro-enterostomy, vagotomy and antrectomy and subtotal gastrectomy in elective treatment of duodenal ulcer: interim report. t3r Med J 1: 455, 1964. Goligher JC, Pulvertaft CN, DeDomball FT, Conveyers JH, Duthie HL, Feather DB. Latchmore AJC, Harro P, Shoesmith T, Smiddy FG, Wilson-Pepper J: Five to eight year results of Leeds/York controlled trial of elective surgery for duodenal
Volume
137. March
1979
After Vagotomy
ulcer. Brit Med J 2: 781, 1968. 17. Jordan PH Jr: A follow-up report of a prospective evaluation of vagotomy-antrectomy for treatment of duodenal ulcer. Ann Surg 180: 259, 1974. 18. Postlethwait RP: Five year follow-up of operations for duodenal ulcer. Surg Gynecol Obstet 137: 387, 1973. 19. Kronborg 0. Malmstrom J. Christiansen PM: A comparison between the results of truncal and selective vagotomy in patients with duodenal ulcer. Stand J Gastroenterol5: 519, 1970. 20. Kronborg 0: Truncal vagotomy and drainage in 500 patients with duodenal ulcer. Stand J Gastroenterol6: 50 1, 197 1. 21. Amdrup E. Jensen H-E: One hundred patients five years after selective gastric vagotomy and drainage for duodenal ulcer. Surgery 74: 321. 1973. 22. Banks S. Marks IN, Louw JH, Brom B: Nine cases of gastric ulcer after vagotomy and drainage for duodenal ulcer. Gut 10: 460, 1969. 23. Kronborg 0: Clinical results 6 to 8 years after truncal vagotomy and drainage for duodenal ulcer in 500 patients. Acta Chir Stand 141: 657. 1975. 24. Whittaker LD, Judd ES, Stauffer Ml-t: Analysis of use of vagotomy with drainage procedure in surgical management of duodenal ulcer. Surg Gynecol Obstet 125: 1018, 1967. 25. Griffith CA, Harkins HN: Partial gastric vagotomy: an experimental study. Gastroenterology 32: 96, 1957.
341
With the purpose of achieving an acceptable cure rate, low mortality, and few sequelae in the surgical treatment of duodenal ulcer, proximal gastric vagotomy without drainage was introduced in 1970 [I,21 and has since gained increasing ground. Results published so far have shown that these expectations on the whole have been met, as it is possible perform proximal gastric vagotomy with practically zero mortality [3-51 and, unlike other types of duodenal ulcer surgery, with minimal risk of severe dumping and diarrhea [6,7], but with recurrence rates up to 10 per cent or more in some series [3,4,8-II]. Definite evaluation of this method cannot be made before the results of surgery for this not inconsiderable number of recurrences are known. The operation most widely used in cases of recurrent ulcer after proximal gastric vagotomy, as well as after other types of vagotomy, is antrectomy (12,131. By studying the results of antrectomy for recurrent ulcer in a group of duodenal ulcer patients treated primarily with some type of vagotomy, that is, truncal vagotomy plus drainage, selective vagotomy plus drainage, or proximal gastric vagotomy, it will at the present time be possible to get an impression of the final outcome of proximal gastric vagotomy as treatment of duodenal ulcer. Material and Methods In the period 1966-1973, sixty-eight patients (55 men and 13 women) underwent antrectomy for recurrent ulcer after primary treatment of duodenal ulcer with truncal vagotomy plus pyloroplasty (45) or gast,rojejunostomy (4), From Departmentof SurgeryA,
Bispebjerg Hospital. Copenhagen, Denmark. Reprint requests should be addressed to John Christiansen. MD, Department of Surgery D. Glostrup Hospital, DK-2600, Glostrup. Copenhagen, Denmark.
336
selective vagotomy plus pyloroplasty (15), or proximal gastric vagatomy (4). Sixty-four patients were operated on electively, whereas four underwent antrectomy because of hemorrhage. Recurrences included duodenal ulcer (56 patients), prepyloric ulcer (8), and gastrojejunal ulcer (4). Median age at the time of antrectomy was fifty-five years in men (range, 20 to 77 years) and fifty-four years in women (range, 28 to 62 years). Median time between the primary vagotomy and the antrectomy was twenty months (range, 1 to 85 months). In fifteen patients the antrectomy was combined with truncal vagotomy. Gastrointestinal continuity was restored by Billroth I anastomosis in fifty-one patients and by Billroth II anastomosis in seventeen. Seven patients died during the follow-up period. A seventy-seven year old man died from cardiorespiratory insufficiency six days after acute antrectomy for bleeding recurrent ulcer. Six patients died five to eighteen months after the antrectomy. The cause of death could be traced in every case from hospital records and/or death certificates. One patient was dead on admittance to the hospital after hematemesis and melena, and his disease has been classified as recurrence after antrectomy although the diagnosis could not be verified, as autopsy was prohibited by the relatives. In the remaining five patients death had no relation to ulcer disease, and no indications of recurrent ulcer disease were found in hospital or private doctors’ records. One patient had left the country and could not be traced. The remaining sixty patients were reexamined, with a median follow-up of sixty-three months (range, 27 to 120 months). The patients had a personal interview and physical examination by one of us. If any dyspeptic symptoms were present or had occurred since the antrectomy, gastroduodenoscopy and X-ray examination of the stomach and duodenum were performed. One patient who despite persistent severe dyspepsia refused to subject himself to these examinations was listed as having a recurrence. Twenty-four patients had an augmented histamine test performed prior to as well as after the antrectomy.
The American Journal 01 Surgery
Antrectomy
TABLE I
Postoperative Complications After Antrectomy (66*patients)
TABLE II ____.
No. of Patients
1 2 1 4 19 7
Postoperative Gastric Complaints (60 patients)
Visick I Visick II Visick III Visick IV
33 12 7 a
Total
60 (lOO%!
No. of Patients 34 16 3 2
Total
60
TABLE Ill
Antrectomy Peak Acid output (mEq/hour)
(16 patients) Reduction (%)
Antrectomy i- Revagotomy (a patients) Peak Acid output Reduction (mEq/hour) (%)
n
.3
1 1
Postprandial Complaints (60 patients) No. of Patients
Epigastric fullness Mild dumping Severe dumping Diarrhea Periodic vomitina
(55%) (20%) (12%) (13%)
Peak Acid Output and Reduction of Peak Acid Output After Anlrectomy (24 patients)
TABLE V
No complaints Minor postprandial complaints; no dyspepsia Severe postprandial complaints: no dyspepsia Dyspepsia; no postprandial complaints Dyspepsia; minor prandial complaints Dyspepsia; severe postprandial complaints Severe dyspepsia and postprandial complaints. Classified as recurrence
Vagotomy
Clinical Results After Antrectomy (60 patients)
TABLE IV
No. of Patients Thromboembolic complications Acute pancreatitis Intraperitoneal abscess Anastomotic leakage Pulmonary complications Wound infection
After
17 5 4 6 1
96.7 80.3 32.2 100.0 83.9 82.7 97.6 2.2 100.0 64.9 94.7 6.3 99.6 34.6 10.9 74.2
0.6 5.6 13.0 0 3.0 4.8 0.6 17.4 0 6.8 1.0 16.0 0 6.8 21.2 5.0 (6.4 f
1.8)
(66.3 f 9.3)
11.4 4.3 9.2 1.2 0.6 4.4 1.4
49.6 74.3 53.1 87.5 96.7 85.4 96.2
13.8
57.7
(5.8 f
1.5)
(75.1 f 6.8)
Note: Numbers in parentheses indicate mean values f SEM.
Results
There was one postoperative death (see Material and Methods), compared with an operative mortality rate of 1.5 per cent (95 per cent confidence limits, 0.0 to 7.9 per cent). Splenic injury requiring splenectomy occurred in four patients. Postoperative complications are shown in Table I. In two of four patients with anastomotic leakage, reoperation was required. Two patients underwent reresection twenty-two and thirty-six months later because of relative stenosis and delayed gastric emptying. Recurrent ulcer was not demonstrated in these two patients either prior to or during the operation. Two patients (2.9 per cent; 95 per cent confidence limits, 0.4 to 10.2 per cent) were classified as having recurrent ulcer. One had dyspepsia as before the antrectomy but refused further examinations, and one died from upper gastrointestinal hemorrhage (see previous section).
Valmw~lR7
March
1979
Of the remaining patients reexamined, twenty-five had some degree of dyspepsia and/or postcibal symptoms. (Tables II and III.) The overall clinical status at follow-up according to the Visick grading is shown in Table IV. Histamine-stimulated acid secretion was studied before and after antrectomy in twenty-four patients. (Table V.) No significant difference in postoperative peak acid output or reduction of peak acid output could be demonstrated between patients with antrectomy and patients with antrectomy plus vagotomy (p > 0.10). Furthermore, no correlation could be demonstrated between persisting dyspepsia and postoperative peak acid output or reduction of peak acid output. Comments
Combined vagotomy-antrectomy seems to be the most effective treatment of duodenal ulcer, since recurrence rates are of the order of magnitude of 1
3.79
Jess, Christiansen,
and Svendsen
per cent even after long-term follow-up [7,14-181. This operation does however carry a mortality of up to 1 per cent and a frequency of postoperat.ive gastric complaints such as dumping and diarrhea of 10 to 25 per cent [7,14,15,17]. Truncal vagotomy plus drainage and selective vagotomy plus drainage carry a lower mortality [19,201 but almost the same rate of gastric complaints atid in most series ,a definitely lower cure rate [21-241. Proximal gastric vagotomy was introduced to reduce the frequency of postoperative gastric complaints, as these were supposed to result from the bypass or mutilation of the pyloroantral region which regulates gastric emptying [25]. Higher cure rates than after other types of vagotomy could not be expected on theoretical grounds, especially not compared with selective vagotomy plus drainage, as denervation of the fundic gland area is achieved in the same way. However, a lower mortality possibly could be expected since no drainage procedure is performed. With respect to gastric complaints, results have been according to expectations, as dumping and diarrhea have been reported in only 0.4 to 5 per cent of patients and usually in a mild degree [3,7,8,Il]. Mortality has been low, as in collected series of more than 5,000 proximal gastric vagotomies, which showed a mortality of only 0.3 per cent [12]. Recurrence rates vary, but in some series with a reasonably long follow-up, are rather high (10 to 22 per cent) [3,9-111. The final evaluation of surgical treatment for duodenal ulcer implies knowledge of the results of treatment of the recurrences. In a series of 260 patients with duodenal or prepyloric ulcer treated with proximal gastric vagotomy in our department and followed up for one to four years, thirty-one recurrences (12 per cent) occurred [3]. Antrectomy in these thirty-one patients should result in 0 to 3 recurrences compared with a “final” recurrence rate of 0 to 1.2 per cent (95 per cent confidence limits). No deaths occurred after proximal gastric vagotomy, but after antrectomy in thirty-one patients, a “final” surgical mortality of 0.1 to 2.4 per cent would result. Eight patients were classified as failures after the antrectomy (Visick IV), compared with a final Visick IV rate of 3 percent (range 0 to 6 per cent). If these figures are compared with the results of long-term follow-up after vagotomy-antrectomy [16-181, the “final” cure rate and the mortality after proximal gastric vagotomy will be the same, whereas the number of failures will be a little higher after vagotomy-antrectomy primarily because of a higher frequency of dumping and diarrhea.
340
These calculations should of course be applied with some caution and may be difficult to apply when choosing a treatment in the individual patient. Factors such as the patient’s general physical condition and the surgeon’s technical skill have not been (and could not be) taken into consideration in these calculations but are of obvious importance. The present study once more emphasizes the importance of continued search for preoperative methods to evaluate patients especially prone to postgastrectomy symptoms such as dumping and diarrhea because such patients, according to current knowledge, should be treated with proximal gastric vagotomy, whereas vagotomy-antrectomy probably would offer an advantage for patients not predisposed to these complications. Summarv
Sixty-eight patients antrectomized for recurrent ulcer after different types of vagotomy were reexamined two to ten years after the operation. Mortality after antrectomy for recurrent ulcer was 1.5 per cent (95 per cent confidence limits, 0.0 to 7.9 per cent), the recurrence rate 2.9 per cent (0.4 to 10.2 per cent), and total failure rate (Visick IV) 13.0 per cent (0.4 to 25.6 per cent). If these figures are applied to a series of 260 proximal gastric vagotomies recently reported from our department and compared with data from series of vagotomy-antrectomy as primary treatment of duodenal ulcer, the final surgical mortality and cure rate will be equal, whereas the final failure rate (Visick IV) probably would be less after proximal gastrid vagotomy because of a lower frequency of dumping and diarrhea. References 1. Amdrup E, Jensen H-E: Selective vagotomy of the parietal cell mass preserving innervation of the undrained antrum. Gastroenterology 59: 522, 1970. 2. Johnston D, Wilkinson AR: Highly selective vagotomy without a drainage procedure in treatment of duodenal ulcer. 8r J Surg 57: 269, 1976. 3. Holst-Christensen J, Hansen OH, Pedersen T, Kronborg 0: Recurrent ulcer after proximal gastric vagotomy for duodenal and pre-pyloric ulcer. Br J Surg 64: 42, 1977. 4. Johnston D: Operative mortality and postoperative morbidity of highly selective vagotomy. Br Med J 4: 545. 1975. 5. Jordan PH Jr: Parietal cell vagotomy without drainage for treatment of duodenal ulcer. Arch Surg 111: 370, 1976. 6. Jordan PH Jr: Current status of parietal celivagotomy. Ann Surg 164: 659, 1976. 7. Sawyers JL. Herrington JL Jr, Burney DP: Proximal gastric vagotomy compared with vagotomy and antrectomy and selective gastric vagotomy and pyloroplasty. Ann Surg 186: 510. 1977. 8. Amdrup E, Jensen H-E, Johnston D. Walker BE, Goligher JC: Clinical results of parietal cell vagotomy two to four years after operation. Ann Surg 180: 279. 1974. 9. Jensen H-E: Personal communication in Jordan PH: Current
The American Journal of Surgery
Antrectomy
10.
11.
12.
13. 14.
15.
16.
status of parietal cell vagotomy. Ann Surg 184: 659, 1976. Kennedy T, Johnston, GW, Malrae KD. Spencer EFA: Proximal gastric vagotomy: interim results of a randomized controlled trial. f3r MedJ 2: 307, 1975. Kronborg 0. Madsen P: A controlled randomized trial of highly selective vagotomy versus selective vagotomy and pyloroplasty in the treatment of duodenal ulcer. Gut 16: 268, 1975. Kronborg 0: A follow-up of patients operated upon for recurrence after vagotomy and drainage for duodenal ulcer. Stand J Gastroenterol8: 123, 1973. Mead PH: Experience with pyloroplasty and vagotomy. Am J Surg 114: 910, 1967. Edwards LW, Edwards WH, Sawyers JL, Gobbel HW, Herrington JL. Scott HW: The suraical treatment of duodenal ulcer bv vagotomy and antral-resection. Am J Surg 105: 352, 1963. Goligher JC, Pulvertaft CN, Watkinson G: Controlled trial of vagotomy and gastro-enterostomy, vagotomy and antrectomy and subtotal gastrectomy in elective treatment of duodenal ulcer: interim report. t3r Med J 1: 455, 1964. Goligher JC, Pulvertaft CN, DeDomball FT, Conveyers JH, Duthie HL, Feather DB. Latchmore AJC, Harro P, Shoesmith T, Smiddy FG, Wilson-Pepper J: Five to eight year results of Leeds/York controlled trial of elective surgery for duodenal
Volume
137. March
1979
After Vagotomy
ulcer. Brit Med J 2: 781, 1968. 17. Jordan PH Jr: A follow-up report of a prospective evaluation of vagotomy-antrectomy for treatment of duodenal ulcer. Ann Surg 180: 259, 1974. 18. Postlethwait RP: Five year follow-up of operations for duodenal ulcer. Surg Gynecol Obstet 137: 387, 1973. 19. Kronborg 0. Malmstrom J. Christiansen PM: A comparison between the results of truncal and selective vagotomy in patients with duodenal ulcer. Stand J Gastroenterol5: 519, 1970. 20. Kronborg 0: Truncal vagotomy and drainage in 500 patients with duodenal ulcer. Stand J Gastroenterol6: 50 1, 197 1. 21. Amdrup E. Jensen H-E: One hundred patients five years after selective gastric vagotomy and drainage for duodenal ulcer. Surgery 74: 321. 1973. 22. Banks S. Marks IN, Louw JH, Brom B: Nine cases of gastric ulcer after vagotomy and drainage for duodenal ulcer. Gut 10: 460, 1969. 23. Kronborg 0: Clinical results 6 to 8 years after truncal vagotomy and drainage for duodenal ulcer in 500 patients. Acta Chir Stand 141: 657. 1975. 24. Whittaker LD, Judd ES, Stauffer Ml-t: Analysis of use of vagotomy with drainage procedure in surgical management of duodenal ulcer. Surg Gynecol Obstet 125: 1018, 1967. 25. Griffith CA, Harkins HN: Partial gastric vagotomy: an experimental study. Gastroenterology 32: 96, 1957.
341