Endoscopic management of peptic ulcer disease.

OBJECTIVE: This article reviews the authors' experience with endoscopic management of duodenal ulcer and ulcers occurring after a previous drainage procedure. SUMMARY BACKGROUND DATA: Patients with complications of duodenal ulcer and ulcers occurring after a previous drainage procedure still require surgical management. Virtually all operations for duodenal ulcer include some form of vagotomy. American surgeons in academic centers prefer highly selective vagotomy in suitable candidates. Video-directed laparoscopic and thoracoscopic operations have been done for all complications of duodenal ulcer except for acute hemorrhage. METHODS: The authors have performed laparoscopic operation on eight patients with intractable chronic duodenal ulcer, seven patients with gastroesophageal reflux disease combined with duodenal ulcer, one patient with chronic duodenal ulcer and gastric outlet obstruction, and one patient with acute perforation. Operations performed included omentopexy, anterior seromyotomy plus post truncal vagotomy, and highly selective vagotomy. Seven patients had a simultaneous Nissen fundoplication; and the patient with obstruction underwent concomitant pyloroplasty and vagotomy. Six patients with intestinal ulcers occurring after a previous drainage procedure were treated with thoracoscopic vagotomy. Techniques used are shown. RESULTS: There has been one recurrent ulcer in the laparoscopic group after anterior seromyotomy plus posterior truncal vagotomy. The patient treated by omentopexy for duodenal perforation recovered gastrointestinal function promptly with no further difficulty, but eventually died of primary medical disease. Patients undergoing thoracoscopic vagotomy have all become asymptomatic. Postoperative hospital stay after highly selective vagotomy, anterior seromyotomy plus posterior truncal vagotomy, or thoracoscopic vagotomy was 1-5 days. CONCLUSIONS: Laparoscopic management of duodenal ulcers is feasible. Larger numbers of patients with longer follow-up are essential. Ulcers occurring after a drainage procedure deserve thoracoscopic vagotomy.     

选择性迷走神经切断术加胃窦切除术治疗十二指肠溃疡远期疗效观察

目的：研究选择性迷走神经切断加胃窦切除术（SV＋A）治疗十二指肠溃疡远期疗效。方法：1977年11月－2001年11月采用SV＋A治疗193例十二指肠溃疡患者,其中顽固性溃疡28例,溃疡伴出血112例,溃疡伴幽门梗阻41例,胃十二指肠复合性溃疡12例。结果：SV＋A术后及术后随访基础胃酸分泌（BAO）、胰岛素刺激后胃酸分泌（IMAO）、五肽胃泌素刺激后胃酸分泌（PMAO）和血清胃泌素显著下降,壁细胞呈现分泌抑制的特征;术后1－10年和11－24年的随访,患者属于Visick I、Ⅱ级分别占95．60％和96．61％,Ⅲ级分别占（4．40％）和（3．39％）,无溃疡复发。结论：SV＋A降酸显著而持久,无溃疡复发。该术式是手术治疗十二指肠溃疡特别是溃疡并发症的有效方法。     

Vagotomy and antrectomy revisited

A retrospective review of 185 patients who underwent truncal vagotomy and antrectomy for duodenal ulcer disease was carried out to determine the mortality and morbidity of the procedure. There were no deaths within 30 days of operation and only one patient died while in the hospital (0.54%). Twenty-one patients (11.4%) suffered early morbidity, 3 of them requiring a second operation. Follow-up was obtained in 83 patients and averaged 13.5 years. According to Visick's classification 75 patients (90.4%) were in class I or II; 5 patients (6%) were in class III and 3 patients (3.6%) in class IV. A recurrent ulcer developed in 2 of the 83 patients. In contrast, after highly selective vagotomy, the literature supports an unacceptable incidence of recurrent ulcer. Therefore, we must not prematurely cast aside vagotomy and antrectomy; it still remains a safe and acceptable procedure for duodenal ulcer disease.     

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.     

Selective treatment of duodenal ulcer with perforation.

Selective treatment of duodenal ulcer with perforation has been based on several premises: 1) The natural history of the ulcer following closure of a perforation is generally favorable with an acute and unfavorable with a chronic ulcer. 2) An upper gastrointestinal series with water soluble contrast media can reliably document a spontaneously sealed perforation. 3) With a spontaneous seal, nonsurgical therapy is an acceptable option and is preferable for an acute ulcer or a chronic ulcer with poor surgical risk. 4) The treatment of choice for an unsealed perforation of an acute ulcer is simple surgical closure. 5) The treatment of choice of perforation of a chronic ulcer with acceptable surgical risk is an ulcer definitive operation. Sixty cases of perforation of duodenal ulcer have been treated. Nonsurgical therapy was employed without complication in eight cases with radiologically documented spontaneous seal. Truncal vagotomy and pyloroplasty in 36 cases and truncal vagotomy and antrectomy in two cases were each without mortality. Four fatalities occurred among 13 cases of closure and omental patch, each a case with severe associated disease. The mortality was 6.7% among the 60 cases; 2.4% for chronic ulcer and 16% for acute ulcer.     

Recurrence after parietal cell vagotomy for peptic ulcer disease

The value of parietal cell vagotomy as a safe surgical procedure in the treatment of chronic peptic ulcer disease has been seemingly limited by the high recurrence rate usually reported. In this 10 year experience of 405 consecutive parietal cell vagotomy operations, 57 patients with recurrent ulceration were evaluated to try to answer the questions of where and why recurrent ulceration appears and how to treat it. Patients with pyloric or prepyloric ulcer disease had recurrence of disease earlier than did patients with chronic duodenal ulcer disease. Consequently, pyloric or prepyloric ulcer patients had a higher recurrence rate in the early postoperative period than chronic duodenal ulcer patients, but this difference disappeared after the seventh postoperative year. Patients with recurrent chronic duodenal ulcer disease have high postoperative acid secretion levels, indicating incomplete vagotomy as a causative factor. Patients with recurrent pyloric or prepyloric ulcer disease have postoperative acid secretion similar to that of patients without recurrence, suggesting another etiologic factor. Thirty of 57 patients with recurrent ulcer had successful medical treatment. A conservative attitude towards recurrences is justified, particularly when symptoms are few and the postoperative acid secretion tests indicate complete or partial vagotomy. Surgical therapy consisting of truncal vagotomy and pyloroplasty in cases of incomplete vagotomy and antrectomy in cases of complete vagotomy should be reserved for patients with symptoms and a disease course that cannot be controlled by conservative treatment.     

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.     

腹腔镜下迷走神经切断加溃疡穿孔粘堵治疗十二指肠溃疡穿孔38例报告

目的:探讨腹腔镜在溃疡穿孔治疗中的应用价值。方法:将明胶海绵卷成锥体栓,尖端塞入穿孔,基底部稍高于浆膜面,均匀滴入生物蛋白胶1.0~1.5m l在明胶海绵栓及其周围,采用H ill术式,切断迷走神经后干和高选择性切断前干。结果:全部病例术后8~9d痊愈出院。全部随访复查胃镜检查溃疡面愈合情况,38例中36例溃疡面愈合,另2例给予内科药物治疗痊愈。结论:腹腔镜下行迷走神经切断术加溃疡穿孔粘堵术治疗十二指肠溃疡穿孔疗效可靠,创伤小,值得推广。     

Vagotomy and double pyloroplasty for peptic ulcer.

Seventy patients with peptic ulcers (55 duodenal and 15 gastric) were treated by truncal vagotomy and doulbe pyloroplasty during the past four years. Clinical and experimental data as presented lead us to believe that transecting the pylorus twice produces an incontinent pyloric sphincter and a larger gastric outlet than is found in other methods of pyloroplasty. This decreases gastric stasis and has led to a lower ulcer recurrence rate (1.5%). In addition the untoward postoperative sequelae are minimal. The 70 patients treated (for the most pare consecutive cases) exhibited the usual complications of peptic ulcer disease. Thirty-three had intractable pain, 23 bleeding (15 massive), 13 obstruction, and one acute perforation. There were no operative or postoperative deaths and the only serious postoperative complication was unrelated to the double pyloroplasty. During the followup period four patients have died of unrelated diseases. Of the remaining 66 patients one developed a probable recurrent peptic ulcer which has responded to medical management. Four patients have intermittent dumping, three have mild diarrhea and one has failed to gain weight, Constipation and weight gain are more common complaints. It would appear that vagotomy with double pyloroplasty is a safe and effective operation for peptic ulcers and that further clinical trials are warranted.     

Gastric response to meat extract stimulation in patients with gastroduodenal ulcer and patients after vagotomy or antrectomy

Gastric acid secretion basally and in response to intragastric meat extract instillation or to tetragastrin, and circulating gastrin concentration basally and after meat extract stimulation were studied in 67 patients with gastroduodenal ulcer, 30 patients after highly selective vagotomy or selective vagotomy for duodenal ulcer, 12 patients after antrectomy for or gastric ulcer and 10 control subjects. Circulating gastrin concentration increased significantly after meat extract stimulation in control subjects, patients with ulceration and patients after highly selective vagotomy, and acid secretion in each group was increased significantly above basal level. In patients after selective vagotomy, significant increase of circulating gastrin concentration was observed, but it was not associated with significant increase of acid secretion. After antrectomy, neither gastrin nor acid secretion increased significantly after meat extract stimulation. In conclusion, present study suggested that (1) gastric acid secretion in response to intragastric meat extract is chiefly affected by the responsiveness of oxyntic cells and release of antral gastric and that (2) the presence of the antrum is almost essential for acid secretion after a test meal, and release of duodenal gastrin after antrectomy would not be so potent biologically as to result in an acid secretion.     

Perforated duodenal ulcer

The records of 131 patients with perforated duodenal ulcer have been reviewed. Sixty-seven per cent of these patients were treated by simple closure of the ulcer or nonoperatively. Of this subgroup, 80 per cent had significant symptoms of peptic ulcer disease requiring medical or surgical treatment and 69 per cent required a second surgical procedure. Thirtyseven patients were treated by a definitive surgical procedure for duodenal ulcer at the time of perforation and all survived. In this group of patients, only one required further surgery for complications of peptic ulcer. We believe that antrectomy and vagotomy or pyloroplasty and vagotomy should be utilized in the treatment of perforated duodenal ulcer unless specific contraindications are present.     

Several standard elective operations for duodenal ulcer: ten to 16 year clinical results.

A survey was undertaken of 558 men with duodenal ulcer who had been treated ten to 16 years previously by truncal vagotomy and drainage, truncal vagotomy and antrectomy and subtotal gastrectomy. Of the 558, 65 had died and 111, presumed living, could not be traced, leaving 382 available for assessment. Between 75 and 85% of the traced patients were considered to have an excellent or very good result, which is a slight improvement on the previously published results in this same group of patients at five to eight years follow-up. Some of the side effects of operation had diminished slightly in frequency and there had been no significant increase in the incidence of recurrent ulceration since the previous survey. Anemia was an uncommon finding. As between the various forms of operation, truncal vagotomy and antrectomy and subtotal gastrectomy demonstrated significantly better protection against proven recurrent ulcer than did truncal vagotomy and pyloroplasty (p less than 0.05). Compared with truncal vagotomy and gastroenterostomy, however, the results of both resection operations, though better, did not achieve statistical significance at p - 0.5 level (p less than 0.1). In regard to Visick gradings the resection procedures had better scores, but the differences were not significant at the p - 0.05 level, except for vagotomy and antractomy as compared with vagotomy and pyloroplasty. But it is stressed that in formulating a policy of surgical therapy for duodenal ulcer the greater inherent immediate risks of resection operations need to be borne in mind.     

Postoperative results of distal partial gastrectomy, selective vagotomy plus antrectomy, and selective proximal vagotomy for duodenal ulcers

We investigated the postoperative results of distal partial gastrectomy, selective vagotomy plus antrectomy, and selective proximal vagotomy, to evaluate their effectiveness in the treatment of duodenal ulcers. The operative mortality of selective vagotomy plus antrectomy and selective proximal vagotomy seemed to be lower when compared to distal partial gastrectomy, although each procedure showed a sufficiently low mortality. The acid reduction rate was significantly lower after selective proximal vagotomy than after the other procedures (p less than 0.01). However, the rate of ulcer recurrence following selective proximal vagotomy tended to be higher compared with the other procedures. All three procedures showed good results according to Visick's grading and postoperative symptoms occurred in about 50 per cent of all patients, no matter what the procedure. The regaining of physical ability was significantly greater following selective proximal vagotomy than following distal partial gastrectomy (p less than 0.05) and the capacity to work was also better after vagotomy, particularly selective vagotomy plus antrectomy (p less than 0.05). Thus, although distal partial gastrectomy and selective vagotomy plus antrectomy proved superior regarding the low ulcer recurrence rate and acid reduction, while selective proximal vagotomy proved superior for improving the quality of life, on the whole, the three operations promise almost equivalent results.     

Truncal vagotomy and pyloroplasty. Critical evaluation of one hundred cases

One hundred patients having truncal vagotomy and Heineke-Mikulicz pyloroplasty on the surgical service of a Veterans Administration hospital performing mainly vagotomy and distal antrectomy were carefully analyzed.In a follow-up study ranging from two to thirteen years, an operative mortality rate of 1 per cent and a proved recurrence rate of 2 per cent were found. The factors involved in the choice of operation for duodenal ulcer were reviewed, and in our hospital the following rates were developed: vagotomy and distal antrectomy, 73 per cent; vagotomy and pyloroplasty, 16.4 per cent; vagotomy and gastroenterostomy, 8.5 per cent; partial gastrectomy, 1.6 per cent; and miscellaneous operations, 0.5 per cent.     

Gastric response to meat extract stimulation in patients with gastroduodenal ulcer and patients after vagotomy or antrectomy

Gastric acid secretion basally and in response to intragastric meat extract instillation or to tetragastrin, and circulating gastrin concentration basally and after meat extract stimulation were studied in 67 patients with gastroduodenal ulcer, 30 patients after highly selective vagotomy or selective vagotomy for duodenal ulcer, 12 patients after antrectomy for or gastric ulcer and 10 control subjects. Circulating gastrin concentration increased significantly after meat extract stimulation in control subjects, patients with ulceration and patients after highly selective vagotomy, and acid secretion in each group was increased significantly above basal level. In patients after selective vagotomy, significant increase of circulating gastrin concentration was observed, but it was not associated with significant increase of acid secretion. After antrectomy, neither gastrin nor acid secretion increased significantly after meat extract stimulation. In conclusion, present study suggested that (1) gastric acid secretion in response to intragastric meat extract is chiefly affected by the responsiveness of oxyntic cells and release of antral gastrin and that (2) the presence of the antrum is almost essential for acid secretion after a test meal, and release of duodenal gastrin after antrectomy would not be so potent biologically as to result in an acid secretion.     

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.     

Selective vagotomy plus antrectomy and Roux-en-Y gastrojejunostomy in the treatment of duodenal ulcer]

From 1982 to October 1990, 284 patients with duodenal ulcer were surgically treated. Partial gastrectomy and Billroth anastomosis (PGB) were performed in 92 patients, selective vagotomy plus antrectomy and Billroth anastomosis (VAB) in 92, and selective vagotomy plus antrectomy and Roux-en-Y gastrojejunostomy (VARY) in 98. Follow-up showed that VARY was superior in many respects to PGB and VAB such as in decreasing gastric acidity, long-term complications and Visick grading of I and II (P < 0.05). We conclude that VARY can be used in the treatment of duodenal ulcer.     

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.     

Fasting and postprandial serum gastrin levels before and after highly selective gastric vagotomy, truncal vagotomy with pyloroplasty and truncal vagotomy with antrectomy: is there a cholinergic antral gastrin inhibitory and releasing mechanism?

Fasting serum gastrin levels and postprandial gastrin response were measured before and 1 month after highly selective vagotomy, truncal vagotomy with pyloroplasty and truncal vagotomy with antrectomy. The three groups of patients, 12 in each group, were closely matched for age, sex, maximum acid output and completeness of vagotomy. After highly selective and truncal vagotomy an identical and significant increase in fasting gastrin was observed, whereas after truncal vagotomy with antrectomy the pre- and postoperative fasting gastrin levels were not different. The net postprandial gastrin output over basal value was significantly increased after highly selective vagotomy, unchanged after truncal vagotomy and significantly lowered after truncal vagotomy with antrectomy. These results suggest the presence in the intact subject of a cholinergic inhibitory mechanism in the gastric body and fundus for the release of antral gastrin in the fasting and postprandial states and a possible cholinergic facilitatory mechanism for the release of antral gastrin after meals.     

Postoperative results of distal partial gastrectomy,selective vagotomy plus antrectomy,and selective proximal vagotomy for duodenal ulcers

We investigated the postperative results of distal partial gastrectomy, selective vagotomy plus antrectomy, and selective proximal vagotomy, to evaluate their effectiveness in the treatment of duodenal ulcers. The operative mortality of selective vagotomy plus antrectomy and selective proximal vagotomy seemed to be lower when compared to distal partial gastrectomy, although each procedure showed a sufficiently low mortality. The acid reduction rate was significantly lower after selective proximal vagotomy than after the other procedures (p<0.01). However, the rate of ulcer recurrence following selective proximal vagotomy tended to be higher compared with the other procedures. All three procedures showed good results according to Visick’s grading and postoperative symptoms occurred in about 50 per cent of all patients, no matter what the procedure. The regaining of physical ability was significantly greater following selective proximal vagotomy than following distal partial gastrectomy (p<0.05) and the capacity to work was also better after vagotomy, particularly selective vagotomy plus antrectomy (p<0.05). Thus, although distal partial gastrectomy and selective vagotomy plus antrectomy proved superior regarding the low ulcer recurrence rate and acid reduction, while selective proximal vagotomy proved superior for improving the quality of life, on the whole the three operations promise almost equivalent results.