Surgical management of acute hemorrhagic postbulbar duodenal ulcer after a previous major surgical procedure

The choice of operation for acute hemorrhagic postbulbar duodenal ulcer after an operation is discussed. Distal partial gastrectomy was performed in six patients. The ulcer was treated by resection, suture, or removal by mucoclasis. Hemostasis was attained in five patients. In another, multiple ulcers were observed in the descending portion of the duodenum and gastrectomy failed to control hemorrhage, resulting in death. Rebleeding was observed in two, one from a newly formed ulcer in the upper part of the papilla of Vater after gastrectomy with truncal vagotomy and which was halted by suture of the ulcer and another was from a newly formed ulcer in the remnant stomach after gastrectomy and which was halted by selective vagotomy and ligation of the left gastric artery. It is recommendable to perform a subtotal gastrectomy and vagotomy combined with removal of the ulcer by mucoclasis or ulcer suture. In some cases, pancreatoduodenectomy may have to be done.     

Treatment of gastroduodenal ulcers perforated into the free peritoneum. Apropos of 122 cases

The treatment used in 122 patients suffering from perforation of gastroduodenal ulcer in free peritoneum is presented. 77 were subjected to straightforward suture of the perforation. Hemigastrectomy was carried out in 43 and in 2 superselective vagotomy associated with removal of the duodenal ulcer and duodenoplasty. Mortality in the series was 11.04% after suture but allowance must be made here for the serious condition of the patients who underwent this form of operation. Of the patients treated with straightforward perforation suture, 36.5% were reoperated for the reappearance of ulcerous symptomatology, while the remaining 63.7% were cured. On the basis of this experience, it is considered that superselective vagotomy associated or otherwise with pyloroplasty, and subtotal gastrectomy are indicated in patients in good general condition and in whom ulcer perforation symptomatology goes back less than 12 hours.     

Bile reflux and degree of gastritis in patients with gastric ulcer: before and after operation

The incidence and degree of bile reflux and gastritis has been measured in normal subjects and in patients with gastric ulcer before operation and after treatment by highly selective vagotomy with ulcer excision, Billroth 1 partial gastrectomy, and truncal vagotomy and drainage. Before operation patients had significantly higher (P less than 0.001) bile acid concentrations in the stomach than normal subjects. Treatment by highly selective vagotomy resulted in significantly lower bile acid concentrations than those before operation and those found after Billroth 1 partial gastrectomy. Antral and body gastritis was significantly less in normal subjects than in the preoperative and all postoperative groups. There was no significant difference in antral or body gastritis between the preoperative gastric ulcer patients and the patients after any of the surgical procedures despite the significant differences in bile acids. Though highly selective vagotomy in the treatment of gastric ulcer results in a reduction in duodenogastric reflux of bile there is no improvement in the gastritis that is present.     

Duodenostomy revisited

Four patients were admitted to the Surgical Ward because of massive bleeding from a duodenal ulcer. In three the ulcer was induced by non-steroid anti-inflammatory drugs. On operation, following pylorotomy and suture of the bleeding artery, neither drainage nor stump closure could be affected safely. Partial gastrectomy with vagotomy, or high subtotal gastrectomy with gastroenterostomy were performed. The duodenum was dealt with by means of a tube duodenostomy. There was no mortality among these patients. Morbidity was related mainly to the extent of preoperative bleeding and associated pathology (e.g. perforation). Patient data is presented in Table I.     

Truncal vagotomy and pyloroplasty for duodenal ulcer.

Two hundred sixty-five patients who underwent vagotomy and pyloroplasty for duodenal ulcer disease were observed postoperatively, 220 for two to ten years, with an average follow-up of five years. Vagotomy and pyloroplasty carried a higher overall recurrence rate (3.6%) than did subtotal gastrectomy and vagotomy (1%), largely because of the high ulcer recurrence rate more than two years after operation for massive bleeding (9.2%) rather than that following elective operation (1.8%). Thirty-five percent of these patients with recurrent ulcers did well with medical management and did not require a second operation. The mortality of vagotomy and pyloroplasty for a massively bleeding ulcer (11%) was less than that following subtotal gastrectomy (21%). The mortality of elective vagotomy and pyloroplasty was 1%.     

Reoperation for postsurgical peptic ulcer recurrence: appraisal of ten years' experience.

Between January 1, 1965 and December 31, 1974, 47 patients were treated at the University of Florida Affiliated Hospitals for peptic ulcer after a generally acceptable ulcer operation. Twenty-seven patients had had vagotomy and drainage, four patients had had vagotomy and antrectomy and 16 patients had had partial gastric resection. Forty-nine definitive operations were performed with a 4% operative mortality. Three patients (7%) had another ulcer recurrence following surgery. Left transthoracic vagotomy is the treatment of choice when recurrent ulceration follows subtotal gastrectomy or vagotomy and antrectomy. For ulceration following vagotomy and drainage, antrectomy, antrectomy is preferred. Synergism between hormonal and neural gastric stimulants causes a decreased parietal cell responsiveness to vagal stimulation after antrectomy. Exploration of the hiatus at the time of antrectomy increases the morbidity of the procedure. Should ulcers recur after antrectomy, vagotomy may be performed with a low morbidity through the transthoracic approach.     

Surgical treatment of 100 patients with perforated pyloric ulcer. Immediate and follow-up results

The aim of this study was to assess the results of different surgical treatments in 100 patients admitted from 1972 to 1984 with perforated pyloric ulcer. Forty-six patients were treated with simple suture, thirty-two patients underwent high selective vagotomy with pyloroplasty, 13 patients were submitted to truncal vagotomy with pyloroplasty and 9 to gastrectomy. This study has shown that high selective vagotomy and pyloroplasty for perforated pyloric ulcer can be performed as safely as simple closure. The overall clinical results according to the Visick classification were recorded as excellent or very good in 85 per cent of patients treated with high selective vagotomy with pyloroplasty versus 38 per cent with similar results in simple closure patients. We conclude that high selective vagotomy with pyloroplasty is not less effective for treatment of pyloric perforated ulcer than for duodenal ulcer; simple closure should be reserved for patients treated long time after perforation and with advanced age or in patients with serious associated pathology.     

Surgical treatment of recurrent peptic ulcer disease.

One hundred twenty patients in whom recurrent peptic ulcer developed after various surgical procedures for primary duodenal ulcer were operated on at the Mayo Clinic between 1970 and 1975. The postoperative mortality rate was 3.3% for all cases, 0.9% for elective cases, and 23% for the 13 patients who required emergency surgical care. The mean hospital stay was 13 days, and postoperative complications developed in 25 patients (20%). Approximately 70% of the patients had excellent or good results, whereas the rest had significant postoperative sequelae, including 8.4% (9 patients) in whom rerecurrent ulceration developed. When remedial surgery for recurrent ulcer consisted of vagotomy and distal subtotal gastrectomy (35 patients) after previous vagotomy and drainage procedure (21 patients), subtotal gastrectomy (three patients), vagotomy and hemigastrectomy (eight patients), or gastroenterostomy alone (three patients), there were no operative deaths, 74% of 27 patients available for at least a 5-year follow-up had excellent or good results, and rerecurrent ulceration developed in only one patient. These results indicate that vagotomy and resection is a satisfactory operation for recurrent peptic ulcer and that the long-term results after this operation compare favorably with those reported for cimetidine therapy.     

Gallstone disease following antrectomy and gastroduodenostomy with or without vagotomy.

The incidence and prevalence of gallstones has been documented in 289 consecutive patients with peptic ulcer disease, at the time of antrectomy and gastroduodenostomy (with or without truncal or selective vagotomy) and again during a 5-year follow-up period. By comparing the preoperative prevalence of gallstone disease in one age group with the prevalence 5 years after the gastric operation in another group of patients who were 5 years younger at the operation, the incidence of gallstone production due to the gastric operation could be calculated independent of the age factor. Within 5 years of the gastric operation, 18% of the patients who were normal at the time of operation produced gallstones. The incidence of new gallstones during the 5-year postgastrectomy follow-up was the same in men and women, and was increased by 7 to 15% in each age group of men. The incidence of new gallstones was 30% after truncal and 12% after selective vagotomy (p less than 0.05). Gallstone formation seems to be a sequel of Billroth I gastric resection. Truncal vagotomy in addition to the gastrectomy increases the risk of gallstone disease; patients with selective vagotomy and antrectomy had an incidence of postoperative gallstones which was the same as patients with antrectomy alone.     

Surgical treatment of perforated gastroduodenal ulcers

Experience in surgically treating 820 patients aged 15 to 83 years who had perforated gastroduodenal ulcers is summarized. In 576 (70.2%) patients the perforated hole was sutured. Thirty-four (4.2%) patients underwent gastrectomy and 210 (25.6%) had vagotomy with drainage operation on the stomach. After surgery 39 (5.6%) patients died. Mortality rates after ulcer suturing, gastrectomy, and vagotomy with gastric drainage were 6.2, 2.7, and 0.9%, respectively. Recurrent ulcer occurred in 57.3% after ulcer suturing, in 2.9% after gastrectomy, and in 9% after gastric drainage vagotomy. By taking into consideration the high rate of recurrent ulcers following palliative interventions, the author proposes to expand indications for radical surgery in patients with serous and serofibrinous forms of general peritonitis in the reactive phase.     

Prospective, randomized trial of selective proximal vagotomy with ulcer excision and partial gastrectomy with gastroduodenostomy in the treatment of corporeal gastric ulcer

In a prospective, randomized trial, selective proximal vagotomy with complete ulcer excision was compared with partial gastrectomy with gastroduodenostomy for the treatment of primary corporeal gastric ulcer in 30 patients. The results were evaluated by clinical follow-up examinations at regular intervals, endoscopy, and blood tests. The mean follow-up period was 3 years for both operations. There was no mortality. Postoperative complications, ulcer recurrence rates, the overall clinical results (Visick classification), and blood test results were similar in the two groups. Three of 15 selective proximal vagotomy patients were classified grade IV due to recurrent ulcer (two patients) or dumping (1 patient), and 2 of 14 partial gastrectomy patients as were classified grades III (epigastric pain) and IV (recurrent ulcer). Considering the risk for late symptoms of impaired resorption and gastric cancer after partial gastrectomy, the similar results with selective proximal vagotomy and partial gastrectomy justify further trials of selective proximal vagotomy with ulcer excision for treatment of corporeal gastric ulcer.     

Modified segmental gastrectomy combined with vagotomy for a gastric ulcer near the gastro-esophageal junction

To avoid proximal gastrectomy which destroys the gastroesophageal closing mechanism, modified segmental gastrectomy with vagotomy was performed on 3 patients with gastric ulcers located in the stomach near the gastro-esophageal junction. These were all patients in whom a proximal gastrectomy would usually have been performed. The proximal line of resection did not encroach upon the mucosal rosette being within 1 cm of it following the margin of the ulcer. In each patient, the modified segmental resection of the upper stomach consisted of the surgical removal of a continuous strip of tissue including the ulcer and ulcer-bearing area along the wall followed by an end to end gastro-gastrostomy. In the 10 years following surgery, there have been no signs of reflux esophagitis, stricture, or recurrent ulcers in any of the 3 patients. This modified segmental gastrectomy with vagotomy is therefore recommended for gastric ulcers located near the gastro-esophageal junction.     

Operative management of stress ulcers in children.

The operative management of stress ulcer in children is controversial. Between the years 1969 and 1981, ten children were operated on at the Babies Hospital for stress ulcer. Their illnesses included connective tissue disorders (3), sepsis (2), Reye's syndrome (1), hemolytic uremic syndrome (1), leukemia (1), closed head injury (1), and renal failure (1). In those with bleeding (8), aggressive conventional medical management was attempted prior to operation. Four children also received intravenous cimetidine. Four patients underwent embolization of a feeding artery and/or selective vasopressin infusion. In those patients who perforated (2), operation was performed after a brief period of resuscitation. Ten patients underwent 11 operations. In those who bled, multiple ulcerations were the most common finding. Operative procedures consisted of partial gastrectomy and vagotomy (4), partial gastrectomy alone (2), and vagotomy and pyloroplasty (2). One child who underwent vagotomy and pyloroplasty required partial gastrectomy for recurrent bleeding. Of the two children who perforated, one was managed by plication and the other by partial gastrectomy. There were two deaths (20%), both occurring in patients who had undergone gastrectomy. One survivor has mild dumping. This experience suggests that in children (1) stress ulcers are commonly multiple when associated with major medical illnesses; (2) partial gastrectomy with or without vagotomy affords maximum protection against recurrent bleeding; (3) lesser procedures are effective for solitary bleeding duodenal ulcers or perforation; and (4) selective arterial embolization or vasopressin infusion are unreliable methods for controlling bleeding.     

Contractile function of the gallbladder after gastrectomy

Gallbladder contractile function was observed by B-mode ultrasonography on patients with radical gastrectomy for gastric carcinoma (20 cases), with subtotal gastrectomy for peptic ulcer (36 cases), and with highly selective vagotomy (7 cases). Thirty-one preoperative patients with peptic ulcer were used as control. It was found that within one month after radical or subtotal gastrectomy the average area and the volume of the gallbladder became much larger than that found in control group. The empty rate of the gallbladder was found decreased and the remainder bile increased. Early stage gallstones were found in two cases 11 and 13 months after gastrectomy. The inner diameter of the common bile duct was increased after radical gastrectomy. No definite relationship was found between gallbladder contractile disfunction and the mode of gastroenterostomy. It was also found that highly selective vagotomy had only slight influence on the biliary tract. These results suggest that gastrectomy has significant influence on the function of biliary tract and plays an important role in the formation of gallstones.     

Differentiated approach to surgical treatment of patients with perforated duodenal ulcer

From 1995-2001, 264 patients with perforated duodenal ulcer were treated by the Emergency Surgical Service of Azerbaijan State Medical University in Baku. In a time of evolving standards and scientific understanding of acid peptic disease, a treatment formula was applied with excellent results. Treatment was tailored to the stage of peritonitis by time from perforation. This time was objectively evaluated by analysis of the peritoneal exudate. The value of laparoscopy was also assessed. Simple closure was performed in 94 patients (open procedure in 46, laparoscopic suture of perforated ulcer in 48 patients). Resection was performed in 170 patients (partial gastrectomy Billroth I in 118 patients, partial gastrectomy Billroth II in 18 patients and antrectomy vagotomy in 34). Application of the algorithm reduced mortality after simple closure to 6.4% and after resection to 1.2%.     

Modified segmental gastrectomy combined with vagotomy for a gastric ulcer near the gastro-esophageal junction

To avoid proximal gastrectomy which destroys the gastroesophageal closing mechanism, modified segmental gastrectomy with vagotomy was performed on 3 patients with gastric ulcers located in the stomach near the gastro-esophageal junction. These were all patients in whom a proximal gastrectomy would usually have been performed. The proximal line of resection did not encroach upon the mucosal rosette being within 1 cm of it following the margin of the ulcer. In each patient, the modified segmental resection of the upper stomach consisted of the surgical removal of a continuous strip of tissue including the ulcer and ulcer-bearing area along the wall followed by an end to end gastro-gastrostomy. In the 10 years following surgery, there have been no signs of reflux esophagitis, stricture, or recurrent ulcers in any of the 3 patients. This modified segmental gastrectomy with vagotomy is therefore recommended for gastric ulcers located near the gastro-esophageal junction.     

Clinical results of reoperation after failed highly selective vagotomy

The results after reoperation after failed highly selective vagotomy during a 10 year period have been reviewed retrospectively. Forty of 306 patients (13 percent) underwent reoperation due to recurrent ulcer (25 patients), severe dyspepsia without proved recurrence (12 patients), and gastric stasis without recurrence (3 patients). In the first two groups, 16 patients had a second vagotomy and 17 underwent partial gastrectomy, 10 with gastroduodenostomy and 7 with gastrojejunostomy. The need for a second reoperation was disquietingly high after both revagotomy (5 of 16 patients) and partial gastrectomy with gastroduodenostomy (4 of 10 patients). These results contrasted with a successful outcome in all seven patients who underwent reoperation with partial gastrectomy and gastrojejunostomy. At the time of follow-up, 85 percent of the reoperated patients (34 of 40 patients) were in Visick grade 1 or 2 as determined by their own judgement.     

Recurrent peptic ulcer after surgery in Japan--a nationwide questionnaire survey of 57 institutions]

Patients with recurrent peptic ulcer undergoing surgery were reviewed at 57 institutions by the 18th meeting of the Japanese Research Society of Gastric Surgery. The factors involved in recurrence was analyzed in patients fulfilling the following criteria: the minimum follow-up period was over 5 years, the age was over 15 years, tetragastrin-stimulated acid secretion was measured before surgery, and the recurrence was confirmed by endoscopy or upper gastrointestinal radiography. In 632 patients, the recurrence rate of duodenal ulcer was significantly higher than that of gastric ulcer. However, the duodenal ulcer patients undergoing selective vagotomy and antrectomy did not develop recurrence. A significant difference in the recurrence rate was observed between selective vagotomy and antrectomy and the wide gastrectomy or selective proximal vagotomy. By analysis using the Cox proportional hazard model, the risk factors for recurrence of duodenal ulcer were the ulcer stage, the operative procedure, the location of the ulcer, and the age of the patient. Especially, recurrences in patients receiving selective proximal vagotomy depended on the location of the ulcer and the age, but the risk factors for patients undergoing wide gastrectomy were uncertain.     

Clinical Results of Parietal Cell Vagotomy (Highly Selective Vagotomy) Two to Four Years After Operation

In Leeds and Copenhagen 271 patients were treated electively for duodenal ulcer by parietal cell vagotomy without drainage between 1969 and 1972 inclusive, with no operative deaths. 108 patients have been followed up 2–4 years since operation. Gastric stasis necessitating re-operation occurred in only 2 cases. Gastric ulcer developed in 2 cases, and in 3 cases recurrence of the duodenal ulcer was suspected but was unconfirmed at re-operation. Uncontrolled comparison with the results of partial gastrectomy and of vagotomy with drainage, as performed at these two centers, has shown that after parietal cell vagotomy without drainage there is a much lower incidence of dumping, diarrhea and bile vomiting, and, on overall assessment, a greater proportion of perfect or very good results.     

On the question of functional postvagotomy complications

The intraoperative measures preventing functional complications after vagotomy were determined in performing organ-saving operations on 63 patients with complications of ulcer disease of the duodenum. Truncal vagotomy must be supplemented with draining operation. The draining operations should be carried out with the dissection of the cicatricial-ulcerous infiltration. The gastroduodenal anastomosis in draining operation should be formed by a one-row suture. When performing selective proximal vagotomy and its variants it is necessary to avoid iatrogenic damage of the Laterge nerve and its terminal part--"crow's feet". Mobilization of the abdominal part of the esophagus during different variants of selective proximal vagotomy must be fulfilled along the length not more than 5 cm proximal to the gastro-esophageal passage and to be associated with a correcting operation on the esophagocardial part.