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Pyloroplasty and vagotomy for duodenal ulcer
Pyloroplasty and Vagotomy for Duodenal Ulcer A Four to Eleven Year Follow-Up Study WILFRED T SMALL, MD, Worcester, Massachusetts M REZA JAHADI, MD, Worcester, Massachusetts
Five years ago we reported to this Society our initial results with pyloroplasty and vagotomy for duodenal ulcer in our first 110 consecutive cases. We examined our limited experience at that time to see if the popularity of this procedure, which left the stomach intact and in continuity, was justified. Indeed, it seemed to be then. We now examine this procedure over the longer term, four to eleven years, to see if this popularity deserves to endure. The follow-up studies of those initial 110 cases plus the next fifty-three consecutive cases, to bring the series to December 3 1, 1965, form the basis of this study. Clinical Material
There were twenty-four deaths during the period of this study from January 1, 1958 to December 31, 1965. The causes ranged from an automobile accident two months postoperatively to the infirmities of age. None could be found due to complications of ulcer. However, all of these cases are excluded from the study. Two patients could not be traced ( 1.4 per cent) and were excluded. This left a total of 137 patients to study. We have 100 per cent follow-up in this series of 137 patients. One hundred twelve (81.7 per cent) were personally seen, interviewed, and examined as indicated. A detailed questionnaire similar to the one devised by Hoerr was utilized in following the other twenty-five patients. The causes of death of twentythree of the twenty-four patients excluded from the series are as follows: malignant lesions of various sites, with or without metastases, three patients; cardiac disease, eleven; renal disease, four; hepatic disease, one; cardiovascular accidents, two; accidents, two. Many of these patients were classified as having massive bleeding. Of the 137 patients studied, 102 (74.5 per cent) were male and thirty-five (25.5 per cent) were female. The age distribution of the 137 patients studied is as follows: twenty to twenty-nine years, six patients; thirty to thirty-nine, twenty-one; forty to fortynine, forty-four; fifty to fifty-nine, thirty-three; sixty to sixty-nine, twenty-three; seventy to seventy-nine, From the Memorial Hospital, Worcester, Massachusetts. Presented at the Fiftieth Annual Meeting of the New England Surgical Society, Portsmouth, New Hampshire, September 25-27, 1969. 372
seven; eighty to eighty-nine, three. It is noted that the majority were in the prime middle years of life. Ninetyeight were between thirty and sixty years of age. There was one death in the immediate postoperative period, giving an over-all surgical mortality of 0.7 per cent. This patient, previously reported [I], had recurrent massive bleeding, abdominal carcinomatosis, and massive tumor abqut the duodenum. He again had massive bleeding and died. Table I notes the over-all mortality and the mortality for those patients operated upon to arrest massive bleeding. The mortality in our series when gastrectomy was employed in the years before 1958 was 26.3 per cent. The indications for operation are seen in Table II. In nearly two-thirds of these patients the operation was carried out for intractability. This group must be carefully selected. Lynch et al, [2] reported a group of female patients with minimal symptoms. The minimal operation was performed, but they became worse postoperatively with a new set of problems, at which point they were diagnosed as visceral neurotics. In later years, a few operations were carried out for perforation. We still do not routinely advocate this, because it is still too difficult to select those patients requiring future definitive surgery. Our indications for operation for obstruction and bleeding are obvious. For patients with massive bleeding we have for years maintained a close medical and surgical program of cooperation. These patients have had a minimum of six to eight pints of blood prior to surgery. It is obvious that better preoperative care has played a role in keeping our mortality low. Cooling has been used in a few cases and has been an aid in deferring surgery in extremely ill patients with multiple other problems. Complications have been routine and not particularly troublesome. (Table III.) There were forty-five complications in twenty-eight patients. One hundred and eight (79.5 per cent) had uneventful routine postoperative recoveries. Stoma1 obstruction was the only early technical complication. In one patient reoperation was performed for restoration of continuity. Incomplete vagotomy as a late complication will be mentioned later. There was one esophageal stricture, probably the result of impairment of the blood supply The American
Journal
of Surgery
Pyloroplasty TABLE
Mortality
I
Number of Patients
Type of Procedure Pyloroplasty and vagotomy for duodenal ulcer Operation to arrest massive bleeding Surgery for massive hemorrhage before 1958 treated by gastrectomy
TABLE
II
TABLE
Rates
Indications
Number of Deaths
1
0.7
26
1
3.8
19
5
26.3
for Operation Number of Patients
Indications Massive bleeding Bleeding ulcer Obstruction Intractability Total
26
Per cent 18.8
11 13 87 137
8.0 9.4 63.8
to the lower end of the esophagus, which necessitated dilatation for relief and has not recurred. All other complications were common to any form of abdominal surgery. The long-term results are presented in Table IV. One hundred twenty-three patients (89.9 per cent) had good to excellent results. These patients lead normal lives, subject only to excesses of modern day living, and have normal diets. No patient has experienced any significant weight loss; indeed some have even gained too much weight. The dumping syndrome has not been a problem. Four patients (2.9 per cent) are classified as having fair results. Although they present no evidence of recurrent ulcer, they are not pleased with results of the operation. Their symptoms from time to time run the gamut of gastrointestinal complaints. These patients m,ay well fit into the category of visceral neurotics. The operation failed in ten patients (7.2 per cent). The cause of failure with recurrence is presented in Table V. There were three proved incomplete vagotmies. These patients were reoperated upon using a transthoracic approach. One patient with stenosis of the pyloroplasty had gastrectomy. The cause of recurrence in the remaining six patients was not determined. Two of these patients had subtotal gastrectomy, and four have been treated medically. Of the six patients with TABLE
IV
Results in 137 Patients Eleven Years
Results
Number
Good to Excellent Fair Failure Vol. 119, April
1970
Followed Up for Four to
of Patients 123 4 10
Per cent 89.9 2.9 7.2
for Duodenal
Complications of Pyloroplasty In Twenty-Eight Patients*
III
Mortality (Per cent)
137
and Vagotomy
and Vagotomy
Number of Cases
Complications
4 2 2 1 1 9 2 1 2 8 1
Atelectasis Colitis (nonspecific) Cystitis Esophageal stricture, relieved by dilation Myocardial infarction Pneumonia Pulmonary emboli Recurrent bleeding from ulcer Renal dysfunction Slow gastric emptying Stoma1 obstruction (reoperation necessary) Wound dehiscence Wound infection Congestive heart failure Leakage from gastrostomy site Total * One hundred recoveries.
eight (79.5 per cent)
Ulcer
patients
4 6 1 1 45 had uneventful
recurrence who had secondary operations, none has had a second recurrence. In the patients with long-term follow-up studies there were twenty-five ( 18.2 per cent) patients who experienced diarrhea at one time or another; in none of these patients was it severe or debilitating. Comments Vagotomy and pyloroplasty for duodenal ulcer has now become accepted as the routine operation at our hospital. This was not the case five years ago. Undoubtedly an occasional patient, such as one with recurrence or Zollinger-Ellision syndrome will need some form of extirpative surgery. At this time surgeons are still making elaborate efforts to tailor the operation to the patient and his particular ulcer syndrome. Rosemond and Reichle [3] made an excellent study, and many more such ones are easily found in the literature emphasizing the necessity for selectivity in operation. In general we disagree with this premise and believe that a good vagotomy and good drainage procedure in continuity will suffice for nearly all duodenal ulcer patients. We place strong emphasis on the good drainage procedure. More often than not the scarring and inflammatory reaction about the duodenum precludes TABLE V
Number of Patients 3 1 6
Cause of Failure In Ten Patients rence and Type of Retreatment
Cause of Failure Incomplete vagotomy Stenosis of pyloroplasty Etiology unknown
with
Recur-
Type of Retreatment Transthoracic vagotomy Gastrectomy Medical treatment (4 patients): gastrectomy (2 patients)
373
Small and Jahadi a Heineke-Mikulicz pyloroplasty. We have therefore come to favor more and more a liberal gastroduodenostomy. Mobilization of the duodenum is mandatory to perform this procedure with ease. A stoma of at least 5 cm is also necessary. We have had no emptying problems in patients with gastroduodenostomy. Nearly all surgeons now accept pyloroplasty and vagotomy as the surgical treatment of choice for massive gastroduodenal hemorrhage. Foster, Hickok, and Dunphy [#I and Klingensmith and Oles [5] are but a few of the recent authors that heartily concur with this opinion. We have also found pyloroplasty and vagotomy to be the procedure of choice during the last ten years and have reduced our mortality to minimal levels. Although many of the patients in whom the operation failed had presented themselves with recurrent bleeding as the primary symptom, only one in this series has had rebleeding in the immediate postoperative period. The debate regarding elective procedures for duodenal ulcer continues. However, we shall continue to routinely employ the lesser operation, for our results to date seem to justify that position. This series may be selective only in that the population we have been dealing with is composed of private patients, all of whom have had surgery performed or supervised by five experienced abdominal surgeons. We have not had complete gastric acid studies on all patients. When these studies were performed, we noted that achlorhydria was not produced. A Hollander test and routine gastric acid studies have been carried out in all patients with recurrent ulcer. At the present time we are continuing to employ pyloroplasty and vagotomy as our treatment of choice for the complications of duodenal ulcer. We are willing to accept a slightly higher recurrence rate than that reported in the best series in which extirpative surgery is employed. We hope that when future series are reported and our failure due to technical errors are reduced, this procedure will carry a recurrence rate at least equal to or better than can be accomplished by alternative methods. Summary 1. One hundred thirty-seven patients having pyloroplasty and vagotomy for duodenal ulcer are reviewed. 2. Operative mortaiity rate was 0.7 per cent. Mor-
374
tality in operations performed to arrest massive blceding was 3.8 per cent. 3. Recurrence rate was 7.2 per cent with more than half of the recurrences due to technical failures. References 1. Small
WT, Ashraf M: Pyloroplasty and vagotomy for duodenal ulcer: A Review of a Hundred and Ten Cases. New Eng J Med 212: 619, 1965. 2. Lynch JD, Jernigan SK, Trotta PH, Clemens BE: Incidence and analysis of failure with vagotomy and HeinekeMikulicz pyloroplasty. Surgery 58: 483, 1965. 3. Rosemond GP, Reichle FA: The operation of choice for peptic ulcer disease. Amer J Gastroent 48: 392, 1967. 4. Foster JH, Hickok DF, Dunphy JE: Changing concepts in the surgical treatment of massive gastroduodenal hemorrhage. Ann Surg 161: 968, 1965. 5. Klingensmith W, Oles P: Vagotomy and pyloroplasty for massively bleeding duodenal and gastric ulcers. Amer J Surg 116: 759, 1968.
Discussion JOHN R BRINKS (Boston, Mass) : Doctor Small’s series of vagotomy and pyloroplasty is a beautiful one, and the follow-up study most impressive. He and others have given us at the Peter Bent Brigham Hospital considerable enthusiasm to follow along in their footsteps. It seems to me that massive bleeding of the type Dr Small has just mentioned (2,500 cc or more preoperatively) is the crux of the mortality of duodenal ulcer. Doctor Small’s operative mortality of 3 per cent in patients with massive bleeding is very impressive. Our experience with subtotal gastrectomy has been quite comparable with the series Dr Small described. We have had a 23 per cent operative mortality in patients with massively bleeding duodenal ulcers. This mortality rose to 27 per cent in patients over seventy years of age. This figure is not much different from the mortality in medical treatment of this same disorder. We therefore became disillusioned with gastrectomy for patients with recurrent bleeding, especially older patients. We had a similar series of seventy patients with massive bleeding who had vagotomy and pyloroplasty. Mortality was 12 per cent in this group of patients, all of whom were over seventy years of age. Because of this significant drop in mortality, vagotomy and pyloroplasty has now become our operation of choice in patients with massive bleeding. GEORGE R DUNLOP (Worcester, Mass) : I would like to ask all present now if we, as surgeons, had duodenal ulcers, how many would prefer vagotomy and how many would prefer gastrectomy. [Sixty per cent of those present indicated that they preferred vagotomy; 40 per cent voted in favor of gastrectomy.]
The
American
Journal
of Surgery
Five years ago we reported to this Society our initial results with pyloroplasty and vagotomy for duodenal ulcer in our first 110 consecutive cases. We examined our limited experience at that time to see if the popularity of this procedure, which left the stomach intact and in continuity, was justified. Indeed, it seemed to be then. We now examine this procedure over the longer term, four to eleven years, to see if this popularity deserves to endure. The follow-up studies of those initial 110 cases plus the next fifty-three consecutive cases, to bring the series to December 3 1, 1965, form the basis of this study. Clinical Material
There were twenty-four deaths during the period of this study from January 1, 1958 to December 31, 1965. The causes ranged from an automobile accident two months postoperatively to the infirmities of age. None could be found due to complications of ulcer. However, all of these cases are excluded from the study. Two patients could not be traced ( 1.4 per cent) and were excluded. This left a total of 137 patients to study. We have 100 per cent follow-up in this series of 137 patients. One hundred twelve (81.7 per cent) were personally seen, interviewed, and examined as indicated. A detailed questionnaire similar to the one devised by Hoerr was utilized in following the other twenty-five patients. The causes of death of twentythree of the twenty-four patients excluded from the series are as follows: malignant lesions of various sites, with or without metastases, three patients; cardiac disease, eleven; renal disease, four; hepatic disease, one; cardiovascular accidents, two; accidents, two. Many of these patients were classified as having massive bleeding. Of the 137 patients studied, 102 (74.5 per cent) were male and thirty-five (25.5 per cent) were female. The age distribution of the 137 patients studied is as follows: twenty to twenty-nine years, six patients; thirty to thirty-nine, twenty-one; forty to fortynine, forty-four; fifty to fifty-nine, thirty-three; sixty to sixty-nine, twenty-three; seventy to seventy-nine, From the Memorial Hospital, Worcester, Massachusetts. Presented at the Fiftieth Annual Meeting of the New England Surgical Society, Portsmouth, New Hampshire, September 25-27, 1969. 372
seven; eighty to eighty-nine, three. It is noted that the majority were in the prime middle years of life. Ninetyeight were between thirty and sixty years of age. There was one death in the immediate postoperative period, giving an over-all surgical mortality of 0.7 per cent. This patient, previously reported [I], had recurrent massive bleeding, abdominal carcinomatosis, and massive tumor abqut the duodenum. He again had massive bleeding and died. Table I notes the over-all mortality and the mortality for those patients operated upon to arrest massive bleeding. The mortality in our series when gastrectomy was employed in the years before 1958 was 26.3 per cent. The indications for operation are seen in Table II. In nearly two-thirds of these patients the operation was carried out for intractability. This group must be carefully selected. Lynch et al, [2] reported a group of female patients with minimal symptoms. The minimal operation was performed, but they became worse postoperatively with a new set of problems, at which point they were diagnosed as visceral neurotics. In later years, a few operations were carried out for perforation. We still do not routinely advocate this, because it is still too difficult to select those patients requiring future definitive surgery. Our indications for operation for obstruction and bleeding are obvious. For patients with massive bleeding we have for years maintained a close medical and surgical program of cooperation. These patients have had a minimum of six to eight pints of blood prior to surgery. It is obvious that better preoperative care has played a role in keeping our mortality low. Cooling has been used in a few cases and has been an aid in deferring surgery in extremely ill patients with multiple other problems. Complications have been routine and not particularly troublesome. (Table III.) There were forty-five complications in twenty-eight patients. One hundred and eight (79.5 per cent) had uneventful routine postoperative recoveries. Stoma1 obstruction was the only early technical complication. In one patient reoperation was performed for restoration of continuity. Incomplete vagotomy as a late complication will be mentioned later. There was one esophageal stricture, probably the result of impairment of the blood supply The American
Journal
of Surgery
Pyloroplasty TABLE
Mortality
I
Number of Patients
Type of Procedure Pyloroplasty and vagotomy for duodenal ulcer Operation to arrest massive bleeding Surgery for massive hemorrhage before 1958 treated by gastrectomy
TABLE
II
TABLE
Rates
Indications
Number of Deaths
1
0.7
26
1
3.8
19
5
26.3
for Operation Number of Patients
Indications Massive bleeding Bleeding ulcer Obstruction Intractability Total
26
Per cent 18.8
11 13 87 137
8.0 9.4 63.8
to the lower end of the esophagus, which necessitated dilatation for relief and has not recurred. All other complications were common to any form of abdominal surgery. The long-term results are presented in Table IV. One hundred twenty-three patients (89.9 per cent) had good to excellent results. These patients lead normal lives, subject only to excesses of modern day living, and have normal diets. No patient has experienced any significant weight loss; indeed some have even gained too much weight. The dumping syndrome has not been a problem. Four patients (2.9 per cent) are classified as having fair results. Although they present no evidence of recurrent ulcer, they are not pleased with results of the operation. Their symptoms from time to time run the gamut of gastrointestinal complaints. These patients m,ay well fit into the category of visceral neurotics. The operation failed in ten patients (7.2 per cent). The cause of failure with recurrence is presented in Table V. There were three proved incomplete vagotmies. These patients were reoperated upon using a transthoracic approach. One patient with stenosis of the pyloroplasty had gastrectomy. The cause of recurrence in the remaining six patients was not determined. Two of these patients had subtotal gastrectomy, and four have been treated medically. Of the six patients with TABLE
IV
Results in 137 Patients Eleven Years
Results
Number
Good to Excellent Fair Failure Vol. 119, April
1970
Followed Up for Four to
of Patients 123 4 10
Per cent 89.9 2.9 7.2
for Duodenal
Complications of Pyloroplasty In Twenty-Eight Patients*
III
Mortality (Per cent)
137
and Vagotomy
and Vagotomy
Number of Cases
Complications
4 2 2 1 1 9 2 1 2 8 1
Atelectasis Colitis (nonspecific) Cystitis Esophageal stricture, relieved by dilation Myocardial infarction Pneumonia Pulmonary emboli Recurrent bleeding from ulcer Renal dysfunction Slow gastric emptying Stoma1 obstruction (reoperation necessary) Wound dehiscence Wound infection Congestive heart failure Leakage from gastrostomy site Total * One hundred recoveries.
eight (79.5 per cent)
Ulcer
patients
4 6 1 1 45 had uneventful
recurrence who had secondary operations, none has had a second recurrence. In the patients with long-term follow-up studies there were twenty-five ( 18.2 per cent) patients who experienced diarrhea at one time or another; in none of these patients was it severe or debilitating. Comments Vagotomy and pyloroplasty for duodenal ulcer has now become accepted as the routine operation at our hospital. This was not the case five years ago. Undoubtedly an occasional patient, such as one with recurrence or Zollinger-Ellision syndrome will need some form of extirpative surgery. At this time surgeons are still making elaborate efforts to tailor the operation to the patient and his particular ulcer syndrome. Rosemond and Reichle [3] made an excellent study, and many more such ones are easily found in the literature emphasizing the necessity for selectivity in operation. In general we disagree with this premise and believe that a good vagotomy and good drainage procedure in continuity will suffice for nearly all duodenal ulcer patients. We place strong emphasis on the good drainage procedure. More often than not the scarring and inflammatory reaction about the duodenum precludes TABLE V
Number of Patients 3 1 6
Cause of Failure In Ten Patients rence and Type of Retreatment
Cause of Failure Incomplete vagotomy Stenosis of pyloroplasty Etiology unknown
with
Recur-
Type of Retreatment Transthoracic vagotomy Gastrectomy Medical treatment (4 patients): gastrectomy (2 patients)
373
Small and Jahadi a Heineke-Mikulicz pyloroplasty. We have therefore come to favor more and more a liberal gastroduodenostomy. Mobilization of the duodenum is mandatory to perform this procedure with ease. A stoma of at least 5 cm is also necessary. We have had no emptying problems in patients with gastroduodenostomy. Nearly all surgeons now accept pyloroplasty and vagotomy as the surgical treatment of choice for massive gastroduodenal hemorrhage. Foster, Hickok, and Dunphy [#I and Klingensmith and Oles [5] are but a few of the recent authors that heartily concur with this opinion. We have also found pyloroplasty and vagotomy to be the procedure of choice during the last ten years and have reduced our mortality to minimal levels. Although many of the patients in whom the operation failed had presented themselves with recurrent bleeding as the primary symptom, only one in this series has had rebleeding in the immediate postoperative period. The debate regarding elective procedures for duodenal ulcer continues. However, we shall continue to routinely employ the lesser operation, for our results to date seem to justify that position. This series may be selective only in that the population we have been dealing with is composed of private patients, all of whom have had surgery performed or supervised by five experienced abdominal surgeons. We have not had complete gastric acid studies on all patients. When these studies were performed, we noted that achlorhydria was not produced. A Hollander test and routine gastric acid studies have been carried out in all patients with recurrent ulcer. At the present time we are continuing to employ pyloroplasty and vagotomy as our treatment of choice for the complications of duodenal ulcer. We are willing to accept a slightly higher recurrence rate than that reported in the best series in which extirpative surgery is employed. We hope that when future series are reported and our failure due to technical errors are reduced, this procedure will carry a recurrence rate at least equal to or better than can be accomplished by alternative methods. Summary 1. One hundred thirty-seven patients having pyloroplasty and vagotomy for duodenal ulcer are reviewed. 2. Operative mortaiity rate was 0.7 per cent. Mor-
374
tality in operations performed to arrest massive blceding was 3.8 per cent. 3. Recurrence rate was 7.2 per cent with more than half of the recurrences due to technical failures. References 1. Small
WT, Ashraf M: Pyloroplasty and vagotomy for duodenal ulcer: A Review of a Hundred and Ten Cases. New Eng J Med 212: 619, 1965. 2. Lynch JD, Jernigan SK, Trotta PH, Clemens BE: Incidence and analysis of failure with vagotomy and HeinekeMikulicz pyloroplasty. Surgery 58: 483, 1965. 3. Rosemond GP, Reichle FA: The operation of choice for peptic ulcer disease. Amer J Gastroent 48: 392, 1967. 4. Foster JH, Hickok DF, Dunphy JE: Changing concepts in the surgical treatment of massive gastroduodenal hemorrhage. Ann Surg 161: 968, 1965. 5. Klingensmith W, Oles P: Vagotomy and pyloroplasty for massively bleeding duodenal and gastric ulcers. Amer J Surg 116: 759, 1968.
Discussion JOHN R BRINKS (Boston, Mass) : Doctor Small’s series of vagotomy and pyloroplasty is a beautiful one, and the follow-up study most impressive. He and others have given us at the Peter Bent Brigham Hospital considerable enthusiasm to follow along in their footsteps. It seems to me that massive bleeding of the type Dr Small has just mentioned (2,500 cc or more preoperatively) is the crux of the mortality of duodenal ulcer. Doctor Small’s operative mortality of 3 per cent in patients with massive bleeding is very impressive. Our experience with subtotal gastrectomy has been quite comparable with the series Dr Small described. We have had a 23 per cent operative mortality in patients with massively bleeding duodenal ulcers. This mortality rose to 27 per cent in patients over seventy years of age. This figure is not much different from the mortality in medical treatment of this same disorder. We therefore became disillusioned with gastrectomy for patients with recurrent bleeding, especially older patients. We had a similar series of seventy patients with massive bleeding who had vagotomy and pyloroplasty. Mortality was 12 per cent in this group of patients, all of whom were over seventy years of age. Because of this significant drop in mortality, vagotomy and pyloroplasty has now become our operation of choice in patients with massive bleeding. GEORGE R DUNLOP (Worcester, Mass) : I would like to ask all present now if we, as surgeons, had duodenal ulcers, how many would prefer vagotomy and how many would prefer gastrectomy. [Sixty per cent of those present indicated that they preferred vagotomy; 40 per cent voted in favor of gastrectomy.]
The
American
Journal
of Surgery