Hemigastrectomy and truncal vagotomy in the treatment of duodenal ulcer. With a summary of related secretory data emphasizing preoperative basal acidity and postoperative basal-insulin achlorhydria

We have found carefully performed basal acidity studies before and basal-insulin testing after operation to be very helpful.The preoperative basal acidity data provide a simple physiologic basis for classifying patients and, because of the wide range of fasting gastric acidity from patient to patient (0 to 56.6 mEq/hr), alert one to the magnitude of the secretory problem that one is attempting to correct by means of an operation. (Tables II and IV.)The postoperative basal-insulin data identify the patients who are achlorhydric and consequently protected against recurrence and those who are not and in whom a recurrence may therefore develop. (Table VIII.)The preoperative basal acidity data used in conjunction with the incidence of postoperative basalinsulin achlorhydria serve as an excellent basis for judging the results of different operations and for selecting the most effective procedure for a given patient. (Table VI.)For patients who are not achlorhydric, the postoperative basal-insulin data reveal the quantity of acid still present. This, in turn, indicates whether the patient is in the category that contains the great majority of recurrent ulcers. It also identifies the cases which have the largest amount of residual vagal activity and serves as an additional basis for judging the results of different operations. (Table IX.)These secretory data enabled us to identify hemigastrectomy with vagotomy as a procedure that would in all probability be very effective in preventing recurrent ulceration twenty years before [1,2] the clinical results [4] justified that conclusion and indicated that it would be more effective than other operations in this regard. (Tables VI and IX.)We recommend truncal vagotomy with hemigastrectomy or antrectomy (40 per cent resection) as the procedure of choice for the management of duodenal ulcer when no contraindications to its use are present.We recommend truncal vagotomy with a drainage procedure for poor risk patients undergoing emergency or elective surgery. Many patients over sixty should be managed in this manner.In good risk patients and elective situations in which resection is contraindicated because of disease in the duodenal area, we would call attention to the fact that truncal vagotomy combined with gastroenterostomy has been more effective than when combined with pyloroplasty in controlling acidity especially in the higher preoperative basal acidity zones. (Table VI.) This group of patients might benefit from some selective or modified truncal technic for vagotomy if it can be used with uniform success by qualified surgeons and if the postoperative basal-insulin secretory data indicate that the late results may be expected to be significantly improved over those of truncal vagotomy with drainage.When vagotomy cannot be performed, subtotal gastrectomy (two thirds) of the Billroth II type is indicated. When neither vagotomy nor resection can or should be performed, gastroenterostomy should be used.