The choice of the surgical treatment method in gastric and duodenal peptic ulcer]

Operations were carried out on 966 patients for gastric ulcer (GU) and duodenal ulcer (DU); the ages of 78% of them ranged from 31 to 50 years. 241 patients underwent operation for GU. Stenosing ulcer was found in 21.4%, penetrating ulcer in 37.3%, bleeding ulcer in 29%, perforating ulcer in 8.3%, and ulcer-tumor in 3.4% of patients. Resection of the stomach after Billroth I was conducted in 32.2%, pyloric preserving resection in 43.1%, Spasokukotski?-Finsterer operation in 5.7%, and selective proximal vagotomy with excision of the ulcer in 19% of patients. DU was found in 725 patients. The ulcer was stenosing in 42.2%, penetrating in 37%, bleeding in 14.7%, and perforating in 6.1% of patients. The following operative interventions were performed: gastric resection after Spasokukotski?-Finsterer, selective proximal vagotomy and pyloroplasty, selective proximal vagotomy, Billroth I operation, excision of the ulcer and selective proximal vagotomy, stitching of the vessels. The long-term results were good in 94.5% of patients.     

Clinical trial of vagotomy and pyloroplasty in the treatment of benign gastric ulcer

A clinical trial of vagotomy and pyloroplasty in the treatment of benign gastric ulcer was performed in forty-eight patients. The incidence of recurrent gastric ulcers was 15 per cent. The results were satisfactory in patients undergoing emergency operation for massive bleeding from a gastric ulcer if the patient had not been on ulcerogenic drugs. However, the operation has not been as satisfactory as antral resection for the management of intractable gastric ulcer.     

Surgical treatment of high bleeding gastric ulcer

In the surgical treatment of 68 consecutive patients with benign, high, bleeding gastric ulcer between 1966 and 1981, the following operative procedures were used; high gastric resection in 31 (45.5%) cases, local ulcer excision with truncal vagotomy and pyloroplasty in 23 (33.8%), local ulcer excision with low gastric resection in 11 (16.2%) and a local procedure alone in three (4.5%) cases. Of these 68 operations, 40 (59%) were early elective operations and 28 (31%) acute or emergency operations. Altogether, six (8.9%) patients died postoperatively, all but one after acute or emergency operation. High gastric resection was the most risky operation and five of the six deaths were in this operative group. Nonfatal complications developed in 18 (26.4%) cases but without correlation to the timing or to the type of operation. Early rebleeding during the hospital stay necessitating reoperation occurred in three (4.4%) patients, two of these among the three cases operated on using a local procedure and without a definitive operation. During the follow-up five (7.3%) recurrent ulcers developed, four after local ulcer excision with truncal vagotomy and pyloroplasty and one after high gastric resection. It seems to us that in the treatment of patients with high gastric ulcer, local operation alone is never acceptable. High gastric resection is often technically hazardous with a high postoperative mortality rate. The best methods seemed to be local ulcer excision combinated with truncal vagotomy and pyloroplasty or, perhaps preferably, with low gastric resection.     

Surgery of acute peptic ulcer haemorrhage

During the years 1973-1985, 145 patients with acute peptic ulcer haemorrhage were treated surgically at the Department of Surgery, Turku University Central Hospital. The bleeding site was gastric ulcer in 76 patients; 58 of these were treated by gastric resection and 17 by ulcer excision combined with vagotomy and pyloroplasty. Forty-two out of 69 patients with bleeding duodenal ulcer were treated with partial gastrectomy, the remaining with transfixion and vagotomy and pyloroplasty. The rebleeding rate was 2% and reoperation rate 9% among the patients who had a resection. In contrast 19% of the transfixed and 12% of ulcer excision cases rebled. The primary overall mortality was 12%; 44% of the patients with recurrent bleeding died. Because rebleeding was the most important cause of mortality, partial gastrectomy in bleeding gastric as well as duodenal ulcer may be preferable.     

Surgical treatment of acute complications of gastroduodenal ulcer]

Operations were carried out on 258 patients with perforating ulcer and on 256 patients with acute bleeding from the ulcer. Perforating ulcer was managed by its closure with sutures in 226 patients (87.6%), by its excision with pyloroplasty and vagotomy in 4 (1.5%), and by primary resection of the stomach in 28 patients (10.9%). Postoperative mortality was 4.65%. In acute hemorrhage 221 patients (86.3%) were subjected to resection of the stomach, 6 (2.4%) to vagotomy with economical resection of the stomach, and 29 patients (11.3%) to excision of the ulcer or stitching of the bleeding vessel. The postoperative mortality was 7.8%.     

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%.     

Immediate results of surgical treatment of gastroduodenal ulcer hemorrhage]

From 1979 till 1989 the authors made operations on 145 patients with gastroduodenal ulcerous bleedings, 87 of them were people of young and middle age. Vagotomy with pyloroplasty was successfully used in 110 patients with duodenal ulcerous bleedings. The method of choice at the peak of bleeding from the duodenal ulcer is thought by the authors to be subdiaphragmatic+ vagotomy with pyloroplasty after Heineke--Mikulicz. For delayed operations the authors prefer SPV with pyloroplasty after Finney. The authors consider that pyloroplasty after Finney excludes reflux of the duodenum content to the stomach and the dumping syndrome. Classical gastric resection is thought by the authors to have no alternative for gastric ulcerous bleedings. The authors think that emergency operation is the only correct method for continuing bleeding. Delayed operations were performed on patients with cupped bleeding and massive blood loss, as well as for recurrent bleeding independent of the degree of blood loss and as a rule within the first 24 hs. General lethality was 4.8% and after organ preserving operations--1.8%. In 95.2% of cases good immediate results were obtained, which allows the method to be recommended for wide practice in cases of gastroduodenal ulcerous bleedings.     

Bleeding duodenal ulcer--treatment strategy. A follow-up study

In a follow-up study of 40 patients operated on for a bleeding vessel in a duodenal ulcer by means of ligation, pyloroplasty and vagotomy, we found that 9 patients (23%) suffered from recurrent bleeding, with a fatal outcome in 7 cases (78%). We conclude therefore that this method is unsuccessful, and if haemostasis is not achieved by endoscopic electrocoagulation operative resection is suggested. Where resection indicates too high a risk to the patient, we suggest that the operative procedure is reduced to ligation of the bleeding vessel combined with a medical vagotomy in the form of an H2-receptor antagonist.     

Pyloroplasty in infancy and childhood

Twenty-nine children under 18 years of age underwent pyloroplasty alone or together with other abdominal operations during a 6-year period. The 21 males and 8 females ranged in age from 2 weeks to 17 years (mean, 54 months). Peptic ulcer disease was the indication for operation in only 6 patients, whereas 16 patients underwent pyloroplasty for functional or mechanical gastric outlet obstruction; 8 had the antral dysmotility syndrome. Other indications included colon interposition in five patients and gastric resection and esophagogastric devascularization in one patient each. Only five patients had concomitant vagotomy. Ten other patients with antral dysmotility syndrome were successfully managed medically. Follow-up ranged from 2 months to 6 years (mean, 30 months). Excellent catch-up weight gain occurred in over 90% of children with functional or mechanical gastric outlet obstruction, with the best results obtained in children with antral dysmotility syndrome. One patient had transitory dumping symptoms following colon interposition with pyloroplasty which remitted with diet changes. Two patients eventually died of the underlying disease (familial dysautonomia, gastric cancer). There were two major complications, respiratory arrest and wound dehiscence, each occurring following emergency operations for peptic ulcer disease. Pyloroplasty was effective in improving gastric emptying and produced minimal morbidity even in the absence of vagotomy. The indications for pyloroplasty in children are different than for adults.     

Choice of emergency operative procedure for bleeding duodenal ulcer

In a consecutive series of 201 emergency operations in patients with bleeding duodenal ulcer the size of the ulcer was the only factor that showed a significant correlation with the procedure chosen. Vagotomy, pyloroplasty and underrunning of the bleeding point was performed in 101 cases with ten deaths (10 per cent), partial (Billroth II) gastrectomy in 81 cases with ten deaths (12 per cent), and vagotomy and antrectomy in 16 cases with one death (6 per cent). A patient was more likely to be treated by partial gastrectomy if a giant ulcer with an internal diameter of greater than or equal to 2 cm was found. The results suggest that while vagotomy and pyloroplasty, combined with a direct attack on the bleeding point or excision of an anterior ulcer is an acceptable standard emergency operation for bleeding duodenal ulcer, gastric resection proved to be a satisfactory alternative procedure and should be considered in the technically difficult case with a very large ulcer. A giant ulcer was present in 37 per cent of cases coming to surgery.     

The effect of vagotomy antrectomy or vagotomy pyloroplasty on the response of the antrum to meat extract in duodenal ulcer patients.

In 9 normal and 42 duodenal ulcer patients, acid and gastrin studies were performed. Basal, Oxo and Histalog stimulated acid secretion was conducted on each patient. In 24 patients post vagotomy pyloroplasty or vagotomy antrectomy, these studies were repeated within three months after surgery. Two groups of duodenal ulcer patients were identified; those who did respond and those who did not respond to Oxo stimulation. In the "responders," Oxo stimulated acid output and gastrin secretion increased significantly over basal values. Both vagotomy pyloroplasty and vagotomy antrectomy caused a similar significant decrease in Oxo and Histalog stimulated acid output. In two patients with incomplete vagotomy, antrectomy, but not pyloroplasty abolished the Oxo stimulated acid response. These data suggest that OXO stimulation test can select patients with a significant antral component in whom vagotomy and antrectomy would be the appropriate procedure. Our results also indicate that antrectomy will protect against recurrent ulceration in patients with incomplete vagotomy and may explain the lower incidence of stomal ulceration in patients with vagotomy antrectomy, compared to vagotomy pyloroplasty.     

Perforated gastric ulcer

BACKGROUND/AIMS: Reports about perforated gastric ulcer are scarce and thus it is difficult to settle for a uniform model of operative management. The purpose of the study was to review our experience with perforated gastric ulcer and evaluate the results of gastric resection vs. oversewing of the perforation. METHODS: Within 36 years 77 patients with peritonitis caused by histologically confirmed perforated gastric ulcer were operated. Furthermore, in another 7 microscopic examination revealed that perforation occurred within the gastric cancer. There were twice as many male as female patients. RESULTS: Recently, the overall postoperative mortality (20. 8%) tended to decrease markedly. 32 patients (mean age 49.9 years) were submitted to gastric resection and this procedure was associated with 2.9% mortality. All 3 subjects in whom vagotomy, pyloroplasty and wedge resection of the ulcer had been performed survived. In 40 patients (mean age 61.5 years) only a suture of the ulcer was performed. This procedure was associated with high mortality (1/3 of patients died). Selection criteria included poor general medical status, age, comorbidities, and substantial progression of the inflammatory process. CONCLUSION: Authors believe that emergency gastrectomy is a safe procedure; however, it might be performed without excessive operative risk in only half of the patients.     

Results of five standard operations for elective surgery of duodenal ulcer

459 patients who were operated on electively for duodenal ulcer in the Surgical Department, University of Turku, in 1965-1976 are reviewed. The operations were: Billroth II resection (B II) 95, truncal vagotomy and antral resection (TV-A) 61, selective gastric vagotomy and antral resection (SV-A) 159, vagotomy and pyloroplasty (V-P) 70, and parietal cell vagotomy (PCV) 110 patients. Operative mortality was 0 in B II, 4.9% in TV-A, 0.6% in SV-A, 1.4% in V-P, and 0 in PCV. About 80% of patients were interviewed 3-12 (mean 5-7) years after operation. Dumping, diarrhea and vomiting occurred less frequently after PCV, but dyspepsia was as common as after B II, TV-A, SV-A, or V-P. Recurrence rates were: after B II 2.7%, TV-A 0, SV-A 0.7%, V-P 9.7% and PCV 8.5%. The incidence of good overall results (Visick grades I + II) was similar after PCV and B II (70% and 69%) which was significantly better than after V-P (41%) and compared favorably with TV-A or SV-A (56% and 54%).     

Surgical management of gastric ulcer

The charts of 139 patients operated on for benign gastric ulcer between 1976 and 1980 were reviewed. Indications for surgery included failure of medical management, bleeding, perforation and inability to differentiate benign from malignant disease. Surgical management included hemigastrectomy 29%, vagotomy with antrectomy 27%, vagotomy with pyloroplasty 13%, wedge resection 7% and highly selective vagotomy 4%. Eighty-four patients (60%) were available for a minimum 4-year follow-up. Recurrence rates were highest in those treated by highly selective vagotomy (33%) and wedge resection (30%). The overall death rate was 4.3%, and 70% of the patients were classified as Visick grades I or II (no or minimal symptoms). Of the 30 patients with acute perforation, 21 were treated by omental patching; 1 died and 3 had recurrent ulcer. Of six patients treated by vagotomy with antrectomy, there were no deaths and no recurrences. The authors conclude that lesser procedures are associated with an unacceptable recurrence rate and that gastric resection is the procedure of choice for both elective and emergency management of gastric ulcer.     

Surgical treatment of patients with perforated peptic ulcers

Results of surgical treatment of 782 patients with perforated gastric and duodenal ulcers are analyzed. Gastric ulcers of I type were diagnosed at 86 (10.9%) patients, prepyloric and pyloric ulcers - at 441 (56.4%), duodenal ulcers - at 255 (32.6%) patients. Perforation was combined with bleeding and stenosis at 24 (3.1%). Palliative operations have been performed at 172 (22.0%) patients, stem vagotomy with ulcer excision and pyloroplasty - at 58 (7.4%), various types of stomach resection - at 54 (6.9%), proximal gastric vagotomy with excision of gastric, pyloric or duodenal ulcer - at 77 (9.8%), proximal gastric vagotomy with excision or suturing of ulcer and pyloro- or duodenoplasty - at 421 (53.8%) patients. The rate of postoperative complications after proximal gastric vagotomy was 3.6%, after stomach resection - 18.2% (p<0.01). Early postoperative complications after vagotomy with ulcer excision and pyloroplasty were diagnosed at 8.3%, after stomach resection - at 18.2% patients (p<0.01). The quality of patients life was higher after organ-saving operations. Proximal gastric vagotomy with excision of ulcer and pyloro- or duodenoplasty should be regarded as operation of choice at perforated duodenal ulcers.     

Six-year results of a prospective, randomized trial of selective proximal vagotomy with and without pyloroplasty in the treatment of duodenal, pyloric, and prepyloric ulcers.

In a consecutive series of patients with uncomplicated prepyloric, pyloric, or duodenal ulcer, 39 patients were randomly allocated to selective proximal vagotomy with pyloroplasty, and 40 patients to selective proximal vagotomy alone with no operative mortality. Before surgery, all patients had undergone H2-receptor antagonist treatment. No patient was lost for follow-up. At an average follow-up of 6 years, recurrent ulcer was recorded in 15% and 20%, respectively, after selective proximal vagotomy with and without pyloroplasty. Three of 14 recurrent ulcers were asymptomatic. Epigastric pain with or without ulcer was significantly less common after selective proximal vagotomy with (13%) than without pyloroplasty (40%). Mild diarrhea or mild dumping was recorded in a few patients. The overall results were very good or good (Visick I or II) in 77% and 55% (significant difference) after vagotomy with and without pyloroplasty, respectively, and in 82% and 58%, if asymptomatic ulcers were graded as Visick I or II results. Of the 27 patients with Visick III or IV results, three patients needed no treatment (asymptomatic ulcers), and 10 patients had no symptoms during medical treatment. Two patients with vagotomy and pyloroplasty and nine with vagotomy alone were reoperated. There were no deaths, and the results were graded as Visick I or II in 10 patients and as Visick III in one patient. The authors conclude that selective proximal vagotomy with pyloroplasty is superior to vagotomy alone for the treatment of prepyloric-pyloric and duodenal ulcer. Recurrent ulcer after vagotomy has a benign course and responds well to ranitidine treatment.     

Proximal Gastric Vagotomy: Does It Have a Place in the Future Management of Peptic Ulcer?

Proximal gastric vagotomy (PGV) is a modification of truncal vagotomy, which was introduced by Dragstedt for the treatment of duodenal ulcer (DU) in 1943. It is a technically demanding operation; but when performed by an experienced surgeon, it is safe and gives a cure rate for DU of more than 90%, with minimal side effects. The operation permanently alters the natural history of the disease and may be used for gastric ulcer (GU), with ulcer excision; but it is not as effective. Further adaptations, such as posterior truncal vagotomy with anterior seromyotomy, were introduced to simplify and shorten the operation, but they did not receive wide acceptance. Recently, with the identification of Helicobacter, it was found that DU can also be cured by eliminating the infection. PGV is therefore used electively in patients with persistent DU that is not Helicobacter-positive or in the few in whom Helicobacter cannot be eliminated. In patients with bleeding or perforated DUs, PGV may be used in conjunction with underrunning the vessel or patching the perforation. However, few surgeons doing emergency peptic ulcer surgery have experience with PGV, so simple suture followed by medical treatment is the safest option. Because elective PGV is now a rare procedure, patients should be referred to a center with special expertise. If Helicobacter becomes resistant to antibiotics in the future, surgery may be needed regularly again, but the technical nuances would have to be relearned.     

Revision operations following vagotomy

Recurrent duodenal ulceration after highly selective vagotomy is best managed by antral gastric resection and gastroduodenostomy (BI). In cases of gastral localisation of the recurrent ulcer and in cases with high postoperative acidity a 2/3 partial gastrectomy (BI) should be performed. Revagotomy after highly selective vagotomy is not feasable in most cases. Pyloric stenosis after highly selective vagotomy occurs in about a percentage of 2 and can be easily corrected by secondary pyloroplasty or duodenoplasty. In very rare cases of severe postvagotomy dumping and postvagotomy diarrhoea the interposition of an antiperistaltic jejunal segment can be practised. Persisting postvagotomy dysphagia may require pneumatic dilatation of the cardia or operative revision of the oesophago-cardiac region. A case of ulcerocancer in a pyloric ulcer primarily treated by truncal vagotomy and pyloroplasty is reported.     

Prognosis of gastric ulcer: twenty-five year followup.

Four hundred twenty-two patients with gastric ulcer treated during 1950-1960 were followed up to 25 years with a mean followup of 9 years. Nonoperative treatment was used in 59% with a hospital mortality of 35%, one-third of these deaths being directly due to gastric ulcer perforation or hemorrhage. Operative treatment was used in 41% of patients. The most common operation (86%) was gastric resection without vagotomy. Overall operative mortality was 16%; 34% for emergency procedures and 6% for elective procedures. Cachexia seemed to be the most important factor related to operative mortality. Nonoperative treatment resulted in more than twice the hospital mortality compared to operative treatment. Approximately one-half of all patients treated non-operatively had a recurrent gastric ulcer at some time during this study. The recurrence rate following definitive gastric resection was 1.3% compared with 16% during nonoperative therapy. Three-fourths of recurrences occurred later than two years and nearly half of recurrences after more than 5 years of followup. Patients with a prior history of overt bleeding from gastric ulcer disease particularly were at risk for further bleeding. There were coincidental duodenal ulcers in 10% of our patients and a 0.8% incidence of gastric cancer during followup. Long term followup demonstrates the superiority of operative treatment of gastric ulcer and also reveals the continuous propensity of such ulcers to recurrence following nonoperative treatment. Earlier elective operation in patients with overt bleeding, recurrence or persisting symptoms should decrease overall mortality and result in a lower overall long-term risk of ulcer complications.     

Do perforated duodenal ulcers need an acid-decreasing surgical procedure now that omeprazole is available?

If a chronic duodenal ulcer perforates, the choice of operation will depend on the patient's condition. Preoperative shock, concurrent medical diseases, severe generalized peritonitis, or the presence of an intra-abdominal abscess are contraindications to a definitive ulcer operation; hence, simple closure or omental patch closure is performed. Omeprazole can then be used to heal the ulcer in the early postoperative period, with long-term H2-blocker therapy to follow. The patient without a contraindication to a definitive operation should have a proximal gastric vagotomy in addition to an omental patch closure of the perforation. The addition of this procedure does not change the operative mortality rate in properly selected patients, does not cause the gastrointestinal sequelae associated with truncal vagotomy and pyloroplasty or resection, and has a low rate of recurrent ulcer in experienced hands. The presence of a synchronous posterior "kissing" duodenal ulcer would prompt some to choose a vagotomy and pyloroplasty in preference to a proximal gastric vagotomy. The appropriate operation to perform after perforation of an acute duodenal ulcer in a patient with any of the contraindications listed above is simple closure or omental patch closure. In the stable nonseptic patient, the choice is not as clear. Boey and associates noted cumulative recurrent ulcer rates of 37% and 31% at 3 years in separate studies in which omental patch closure was used for perforated acute duodenal ulcers. This may reflect the asymptomatic nature of chronic duodenal ulcers in some patients prior to perforation, the failure of the surgeon to recognize the extent of periduodenal scarring at operation, or differences in the length of postperforation follow-up in series reporting perforations of acute or chronic ulcers. Jordan has suggested that all stable patients with perforated duodenal ulcers should undergo a proximal gastric vagotomy in addition to omental patch closure. In his hands, the addition of proximal gastric vagotomy has an operative mortality rate of 0 to 1%, a recurrent ulcer rate of 3% to 5%, and no adverse postoperative sequelae. He has noted that "this operation gives protection from further ulcer disease to those who need it and will produce no harm to the unidentifiable patients that might not have benefited from definitive surgery." Boey and Wong suggested that omental patch closure is indicated for "acute ulcers associated with drug ingestion or acute stress" in addition to those that occur in patients who are considered to be poor risk, while proximal gastric vagotomy should be added in the remaining patients with perforations of acute ulcers.(ABSTRACT TRUNCATED AT 400 WORDS)