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Peptic ulcer surgery
JUNE 1978
The
American
Journal
ol Surgery VOLUME 135 NUMBER 8
EDITORIAL
Peptic Ulcer Surgery Frank G. Moody, MD, Salt Lake City, Utah
I don’t know about you, but I’m confused. A few years ago, I could make a decision as to whether a patient should have an operation for duodenal ulcer. Obviously, once the chronicity of the disease has been established, he (or she in increasing numbers) should undergo an acid-reducing procedure. Even my referral doctors were swayed by my point of view. I also knew which operation to perform: pyloroplasty and truncal vagotomy for massive hemorrhage or for persistent disease in the elderly; antrectomy and vagotomy for complications of duodenal ulcer in the middle-aged, hard driving achiever; and total gastrectomy for the patient with Zollinger-Ellison syndrome. But my confidence has been shaken, Now I am led to believe that the Hz receptor inhibitor, cimetidine (called Tagamet@ by the company in the United States that has done so much to establish its efficacy, Smith, Kline & French), can control not only the garden-variety peptic ulcer problems of the duodenum but even the complications of the ZollingerEllison syndrome. This knowledge has been established by randomized controlled trial, and the results have been accepted by the Food and Drug Administration. What more do we need? The nonsurgeons have finally done it: they have found a cure for a disease. But wait. Before you abandon your interest in the care of sick persons with peptic ulcer, consider the following points. (1) Many people will not take the pill. (2) Of those who do take the pill, some will continue to have life-threatening complications from peptic ulcer. (3) Complications from taking the pill From the Department of Surgery, University of Utah, Salt Lake City, Utah. Reprint requests sfxdd bs addressed to Frank G. Moo@, M). DepaNnent of Surgery. University of Utah, Salt Lake City, Utah 84132.
Volume 135, June 1979
are starting to appear, but likely they will be infrequent. (4) Some initial complications of acid-peptic disease (perforation, massive hemorrhage) of the duodenum will require surgical intervention. I therefore recommend: (1) Do not operate on the equivocal case that is sent to you primarily because of upper abdominal pain and an ulcer identified by endoscopy; instead recommend cimetidine. (2) Advise cimetidine for patients with symptomatic Zollinger-Ellison syndrome. The results are dramatic. Call CURE (Center for Ulcer Research and Education) in Los Angeles for further instructions. (3) Continue to do the operation that you do best for the complications of peptic ulcer disease of the duodenum. (4) Consider drainage and vagotomy for the elderly or patients with severe associated disease, especially under the conditions imposed by an emergency procedure. (5) Continue to approach the problem of gastric ulcer as you have in the past. I prefer a distal gastrectomy to include the ulcerated portion of the stomach for this problem. Finally, what is the role of highly selective vagotomy? In my opinion, it represents a sensible approach to the problem of well established but not life-threatening duodenal ulcer disease. But a word of caution: these patients must be followed closely, for the recurrence rate is higher than that with the procedures surgeons now employ. I would advise a careful review of the literature on the subject and a viewing of the movie from the American College of Surgeons Cine Clinic that can be obtained from the film library at Davis and Geck. Most university medical centers are exploring the value of this procedure and would be happy to have surgeons view its performance within their environment. Remain skeptical but receptive. I believe that an improved therapy for ulcers is within our grasp. 731
The
American
Journal
ol Surgery VOLUME 135 NUMBER 8
EDITORIAL
Peptic Ulcer Surgery Frank G. Moody, MD, Salt Lake City, Utah
I don’t know about you, but I’m confused. A few years ago, I could make a decision as to whether a patient should have an operation for duodenal ulcer. Obviously, once the chronicity of the disease has been established, he (or she in increasing numbers) should undergo an acid-reducing procedure. Even my referral doctors were swayed by my point of view. I also knew which operation to perform: pyloroplasty and truncal vagotomy for massive hemorrhage or for persistent disease in the elderly; antrectomy and vagotomy for complications of duodenal ulcer in the middle-aged, hard driving achiever; and total gastrectomy for the patient with Zollinger-Ellison syndrome. But my confidence has been shaken, Now I am led to believe that the Hz receptor inhibitor, cimetidine (called Tagamet@ by the company in the United States that has done so much to establish its efficacy, Smith, Kline & French), can control not only the garden-variety peptic ulcer problems of the duodenum but even the complications of the ZollingerEllison syndrome. This knowledge has been established by randomized controlled trial, and the results have been accepted by the Food and Drug Administration. What more do we need? The nonsurgeons have finally done it: they have found a cure for a disease. But wait. Before you abandon your interest in the care of sick persons with peptic ulcer, consider the following points. (1) Many people will not take the pill. (2) Of those who do take the pill, some will continue to have life-threatening complications from peptic ulcer. (3) Complications from taking the pill From the Department of Surgery, University of Utah, Salt Lake City, Utah. Reprint requests sfxdd bs addressed to Frank G. Moo@, M). DepaNnent of Surgery. University of Utah, Salt Lake City, Utah 84132.
Volume 135, June 1979
are starting to appear, but likely they will be infrequent. (4) Some initial complications of acid-peptic disease (perforation, massive hemorrhage) of the duodenum will require surgical intervention. I therefore recommend: (1) Do not operate on the equivocal case that is sent to you primarily because of upper abdominal pain and an ulcer identified by endoscopy; instead recommend cimetidine. (2) Advise cimetidine for patients with symptomatic Zollinger-Ellison syndrome. The results are dramatic. Call CURE (Center for Ulcer Research and Education) in Los Angeles for further instructions. (3) Continue to do the operation that you do best for the complications of peptic ulcer disease of the duodenum. (4) Consider drainage and vagotomy for the elderly or patients with severe associated disease, especially under the conditions imposed by an emergency procedure. (5) Continue to approach the problem of gastric ulcer as you have in the past. I prefer a distal gastrectomy to include the ulcerated portion of the stomach for this problem. Finally, what is the role of highly selective vagotomy? In my opinion, it represents a sensible approach to the problem of well established but not life-threatening duodenal ulcer disease. But a word of caution: these patients must be followed closely, for the recurrence rate is higher than that with the procedures surgeons now employ. I would advise a careful review of the literature on the subject and a viewing of the movie from the American College of Surgeons Cine Clinic that can be obtained from the film library at Davis and Geck. Most university medical centers are exploring the value of this procedure and would be happy to have surgeons view its performance within their environment. Remain skeptical but receptive. I believe that an improved therapy for ulcers is within our grasp. 731