Aznnals of the Royal College of Surgeons of England (I975) vol 56 ASPECTS OF TREATMENT*

treatment of recurrent peptic ulceration

Assessment

and

David M Steinberg FRACS Bruce A Masselink MD J Alexander-Williams MD chM FRCS

7'TIe

General Hospital, Birmingham

Summary insulin test is negative we normally repeat From the experience of treating 91 patients the test; if it is still negative then we use with a proven recurrent ulcer we consider antrectomy alone. that if a proven ulcer is shown to be present and a gastrin-secreting tumour is ex- Introduction cluded an appropriate reoperation will Recurrent dyspepsia after gastric surgery is a almost always produce a successful result major disappointment to the patient and the surgeon. To the surgeon it also presents a (94/ ). Before subjecting patients to reoperation challenge to secure a precise diagnosis of the all attempts must be made to secure a pre- cause of recurrent symptoms and to convert cise diagnosis. The following investigations a failure into a cure. should be performed: barium meal, panenWe believe that medical treatment has little doscopy of the upper gastrointestinal tract, to offer the patient with a recurrent ulcer and determination of maximum acid output (with therefore that surgery is the best means of Insulin test and gastrin analysis if appropri- treating this difficult group of patients, alate), and cholecystography. Before accepting ready dissatisfied with the initial surgical ata diagnosis of recurrent ulcer at least 2 of tempt to 'cure' their ulcer. However, it is the first 3 tests should be positive. important to be absolutely certain that the If the primary operation was a resection diagnosis of recurrent ulcer is unequivocal as wve advocate vagotomy alone as the second reoperation designed to cure recurrent ulcer operation, provided there are no local has little success with non-ulcer dyspepsia'. complications such as stenosis, bleeding, or The diagnosis of recurrent ulcer can be fistula. If the primary operation was a vago- difficult to establish, particularly when relitomy and the recurrence is associated with ance is placed on radiology alone. Gastritis, a positive response to the insulin test we ad- oesophagitis, and biliary and pancreatic disvocate revagotomy and antrectomy. If the ease must be excluded as causes of recurrent

'Fellows iinterested in submittinig papers for this series should first write to the Editor.

conisiderationi

with a view to

lpublication

in

136

1) M kSteitnber(1B 1 Mlssclink. (at(1 J illcx(al(l('er-Willi(Ims

dyspepsia before treatment for recurrent ulceration is considered. This paper is based on the experience of trcating 9i patients with recurrent ulceration.

with recurrent peptic ulceration and separate them from those who present with recurrent clyspeptic symptoms from other causes. The assesstmlent should also aim to show any underlying cause for the development of recurrent Material peptic ulcer disease. Approximately half of During the period 1950-69 we trcated 5I the dissatisfied patients after peptic ulcer surpatients for recurrent ulcer. From a retro- gery will be proved to have a recurrent ulcer2. spective analysis of this experience we evolved a rationale of management. Since then we Clinical assessment Pain similar in charhave subjected 39 patients to reoperation acter and site to that present with the primary for recurrent ulcer and one has been treated ulcer is present in 70%/, of patients with by gastric irradiation. The major part of this proven recurrent ulcer. However, 65°% of report concerns the group treated since patients with antral gastritis, cholelithiasis, and suture granulomata after gastric surgery 1970. The first 51 patients were treated in one or have a similar pattern of symptoms. Haemaother of two suraical units in the United Bir- temesis, melaena, and/or associated bleeding mingham Hospitals; of these, 35 had had with anaemia are much more likely to be due their primary surgery elsewhere. The remain- to recurrent ulcer than to non-ulcer dyspepsia. The mean time interval for return of symping 40 patients were all treated in the same surgical unit. Of the 20 patients in this group toms due to a recurrent ulcer is much shorter who had had their primary surgery in our after vagotomy procedures (I. 5 years in the unit, in I9 the recurrence followed a vago- present series) than after gastric resection tomy procedure. This represents a recurrence (5.5 years). Moreover, the recurrent ulcer appears to be attended by more serious comrate from 350 vagotomies of 5.4%. Since ig7o we have documented the clin- plications when the first operation was ical and operative records and follow-up in- resection than when it was vagotomy. Four formation obtained by questionnaire on a patients suffered gastrojejunocolic fistula, all prospective basis. The primary surgery carried after resection, in the early part of this study. out on the two groups is shown in Table I. Three of the 4 patients with severe bleeding since I970 have all had stomal ulcers after Methods of assessment resection. The aim in assessment is to identify patients Radiology The barium mcal was the method of assessment only regularly tused beTABLE I Primary operation for ulcer in pafore I970. It had a diagnostic accuracy of tients with proven recurrence approximately 70%. Since 1970, whlen we Primary operation I950-69 1970-73 began a system of documentation designed to permit a prospective study, the overall acGastroenterostomy I I0 Gastrectomy curacy of X-rav diagnosis was found to bc I2 Billroth II (Pola) 5 65 %o, with 3 false positives. Accuracy was Billroth I 7 2 in patients with recurrence after Billroth high 22 30 Vagotomy and drainiage II gastrectomy (ioo%) but there was considVagotomy without drainage 2 erable difficulty in the interpretation of Total 40 51 pyloroplastv channel ulcers (6o% accturacy).

Alssessment (and treatment of recurretnt IPetic ulce(ration

I f37

The insulin test is the only reliable postCertainly onc cannot rely on radiology alone, partictularly after vagotomy procedures. The operative method of assessing the adequacy of pyloroplasty region is recognized being vagotomy. A positive response according to Hollander's criteria is an accurate indicator fraught with diagnostic difficulties. but in our series a Endoscopy was not used of recurrent ulceration, Endoscopy not mean that a recurrent did result negative before I970. We have now used this method present, 6 ulcers being found in of investigation in 23 cases with an accurate ulcer was not with a negative response. Io patients interpretation in I 7 (74%). More recently, A previous report using the advanced end- and side-viewing in- Cholecystography that unit' gallbladder disthis showedl to nearly has increased from this struments. I00%Panendoscopy of the upper gastrointestinal ease could produce similar symptoms in a tract should also help in the detection of patient after vagotomy. We believe that a cholecystogram should be included in the oesophagitis and prestomal gastritis. assessment of postvagotomy and postgastrecApart from those Gastric acid studies tomy dyspepsia, presenting as emergencies, all patients should In patients with a have a basal and a pentagastrin-stimulated Gastrin analysis gastric secretion test. Acid secretion tests were proven recurrent ulcer an cstimation of the carried out on 31 of our patients, all since serum gastrin level should be used to excltude 1970. They gave useful supportive informa- the possibility of a gastrin-secreting tumour tion, particuilarly in indicating that the patient or retained antrum. lhad sufficient acid output to permit peptic digestion. All but 3 of our patients with Results of surgery proven ulcers had a pentagastrin-stimulated The many different operapeak acid ouput of more than I5 mmol 1950 -969 (mEq)/h." The recurrent ulcers of 2 patients tions used to treat 5I patients with recurrent vith low stimulated acid levels vere both ulcer between 1950 and I969 are listed in small and had retained suture material in the Table II. There were deaths and a need base3. They may not have had true peptic for 14 further operations. For recurrence after ulcers. gastric resection abdominal vagotomy was as

2

TABLE ii

Operative mana(lgement and results, I950-69

Seconzdary operation

Primary operation

Billroth I Billroth II (Polya) Abdominal vagotomy Vagotomy and pyloroplasty Vagotomy and antrectomy Thoracic vagotomy

Miscellaneous Total

*Onc dcath.

Figures

in

Vagotomny and Success Gastrorate drainage jcjunostomy Billroth II Billroth I 8 O 10/12 2 (I) 2 (I) 2 I 6/io 2* (2) 5* (2) 2 2 0 9/9 5 0 I O 2/2 I 2 (I) I /2 o o o 0 4/8 o 7 (3) I (I) 2 (2) 2 (I) 3/8 2 (2) 2 22 35/53 12 7 TO

parenthcses represent

failures.

138

D M Steinberg, B A Masselink, and J Alexander-Williams

more successful than further gastric resection. Furthermore, one death followed a repeat gastric resection. Transthoracic vagotomv with a 50%/O failure rate fared badly in comparison with repeat abdominal vagotomy and suffers from the inability to confirm the presence of a recurrent ulcer. For recurrent ulcer after vagotomy and drainage both a Billroth I gastrectomy, (8 cures out of 8) and an abdoiininal revagotomy (2 cures out of 2) produced satisfactory results. 1970 1--973 The follow-up in this latter series ranges from 6 to 48 months with a mean of 24 months. One elderly patient (aged 87) was treated with radiotherapy to the stomach with symptomatic relief. The type of reoperation and results of surgery in the 39 patients in whom we found proven recurrent ulcers at operation are shown in Table III. The majority (85%) of ulcers were confirmed histologically.

All patients have been followed up by questionnaire, and by clinical review when symptomatic. Classification as 'success' requires comnplete cure or improvement of symptom status.

Of the 7 vagotomy operations for recurrence after gastric resection, 2 also involved resection of the ulcer and I the suture of a bleeding vessel in the base of an ulcer. In the one failure in this group the patient had a subsequent return of dyspepsia and a small haematemesis, but no recurrent ulcer has been found despite extensive investigation. The majority of patients with recurrent ulcer after vagotomy procedures had a revagotomy via the abdominal route comibined with an antrectomy. Nineteen of the 2I who had successful repeat vagotomy and antrectomy operations are at present completely free from dyspeptic symptoms. Two have mild symptoms, one probably owing to oesophageal regurgitation and the other to prestomal gastritis. The only failure so far has followed TABLE III Operations on 39 patients with a recent operation. This patient had a stenorecurrent ulcer, I970-73 sis of his gastroduodenal anastomosis after Patients Success antrectomy and required a third operation rate (gastroenterostomy); there was no evidence of recurrent ulceration at this last operation. Reccurrence after gyastric resectioni Three operations were performed as emerVagotomy 7 (l) 6/7 2 for bleeding and I for perforation. genCies, Recurrence after vagotomnvt In the of our experience at this stage light 21 22 Revagotomy and antrectomny 22 ( we thought revagotomy and antrectomy to Antrectomy only (30 % gastrectomy) 3 3 3 be unduly hazardous for these patients. HowBillroth I gastrectomy ever, we now believe that if the surgeon is (gastric ulcer) 3 3/3 experienced in the technique of vagotomy Revagotomy and pyloroplasty I* I/ and antrectomy and if the patient is fit enough Revagotomy and this operation should be used even as an gastrojejunostomy I* I/ Thoracic vagotomy and emergency. It is of interest that one patient gastrojejunostomy I */( I) I who was treated by thoracic vagotomy beRecurrence after gastroenterostomy cause it was thought that abdominal vagoVagotomy and pyloroplasty I I/I tomy would prove technically difficult is the Total 39 (3) 36/39 only patient in this group who still has a proven recurrent ulcer following the second *Emergency operation. Figures in parentheses represent failures. No deaths. operation.

Assessment and treatment of recuirrent peptic ulceratiotnl

I 39

Complications, 39 operations, rent ulcer after Polya gastrectomy in this era. We concur with the view of Nyhus5 that Deaths o non-operative treatment for anastomotic ulcer should rarely be considered. There is little Operative Rupture of spleen evidence of the efficacy of medical treatI 'lorn oesophagus I ment. Beal' found a high mortality due to Immediate bleeding I bleeding, gastrojejunocolic fistulae, and perPostoperative Bowel obstruction 3 foration after medical treatment. All the Major wound infection 3 patients with gastrojejunocolic fistulae in our Mlajor respiratory infection 5 early series had had long periods of medical TABLE IN" I970-73

Perforation of anastomosis Subsequent surgery (before leaving hospital) Late anastomotic breakdown Hold up at gastroduodenal anastomosis Small-bowel obstruction (adhesion)

I

I I

I

Table IV shows the complications of this series of secondary operations. There have been considerable technical difficulties, especially in mobilizing the dense adhesions between the previously dissected oesophagus and the pyloroplasty site and the under-surface of the liver. There were no deaths, but one patient had a major postoperative haemorrhage, presumably from an injured liver, the spleen was ruptured on one occasion, and the lower oesophagus was torn in another. In these 3 cases we had not followed the rules of complete division of adhesions and mobilization of the left lobe of the liver to obtain access to undisturbed oesophagus at the hiatus.

Discussion In the management of recurrent peptic uilceration each era of primary surgery has brought its own peculiar problems of diagnosis and therapy. The evolving pattern of recurrent ulcer management has been partly due to the changing phases of primary surgery, with vagotomy becoming the more popular initial operation for peptic ulcer since I960. Vagotomy was used as the primary operation only once before I960, whereas there were io operations for recur-

management. No comparative trials are avail-

able, but we have tended to adopt a surgical approach to this problem. Reoperation for symptomatic conditions other than recurrent ulcer, such as gastritis, has proved unsatisfactory and therefore every attempt must be made to secure a higLL degree of accuracy in the diagnosis1'3. In this series satisfactory results have been obtained provided the operation has been undertaken for a definite recurrent ulcer. The surgical policy since I970 has evolved after evaluating the results of the previous 2 decades 1950-69 thus: I) For recurrence after gastric resection repeat gastric resection had a high mortality (20%) in the 1950-69 era; furthermore the results were not as good as following an abdominal vagotomy. Abdominal vagotomy is now the method of choice provided there is no evidence of a gastrin-secreting tumour or retained antrum. 2) If the operation is an emergency onc for stomal ulcer complicated by bleeding or perforation we would add either suture or local excision of the ulcer. 3) For duodenal or stomal recurrence following vagotomy the chief lesson learnt, mainly from the second decade (I96o-69), was that thoracic vagotomy had a poor record, with 3 failures out of 7. However, Billroth I gastrectomy, with 8 cures out of 8, and a repeat abdominal vagotomy, 2 cures out of 2, both gave excellent results. Further-

140

D M Steinberg, B A Masselink, and J Alexander-Williams

more, reports of a very low recurrence rate (o.5%/O) after vagotomy and antrectomy7 and dissatisfaction after revagotomy alone' have enCOUraged uls to adopt a policy of abdominal revagotomy with antrectomy after vagotomy procedures. This approach is designed to; deal a double physiological blow to acid production and should be the best insurance against any further ulceration in this group of patients who already have suffered one unsuccessful operation. The majority of patients with recurrent ulcer after vagotomy and drainage have therefore had a revagotomy with antrectomy. There was only i failure to cure symptoms in 22 operations. In 3 patients, when a reliable insulin test indicated a complete vagotomy, antrectomy alone gave good results. 4) For recurrent gastric ulcers after vagotomy for gastric ulcer we advocate a standard Billroth I gastrectomy with excision of the ulcer. For a gastric ulcer occurring after primary surgery for duodenal ulcer the acid analysis and insulin test provide a guide to management. If high levels of acid are present we recommend a revagotomy and antrectomy. If acid levels are low (for example, peak acid output with pentagastrin stimulation < I 5 mmol (mEq)/h) and the ulcer appears to be secondary to stenosis rather than hyperacidity we would perform a Billroth I gastrectomy alone. Adopting this approach to recurrent ulcer on a prospective basis (1970-73) a success

rate of 94%/' has been obtained in 36 patients with a mean follow-up of 24 months. We believe that this length of follow-up is sufficient on which to base conclusions because when second operation failed in the previous 2 decades (1950-69) the majority of patients (I2 out of 14) had their symptoms return within one year. D M S is supported by a Raine Travelling Scholarship from the University of Western Australia. J A-W is a member of the External Scientific Staff of the Medical Research Council.

References Steinberg, D M, and Alexander-Williams, J. In press. 2 Baron, J H, and Alexander-Williams, J (I973) in Recent Advances in Surgery ed. S Taylor, 8th edn. Edinburgh and London, Churchill I

3 4

5

6

7

8

Livingstone. Steinberg, D M, Green, G, Toye, D K M, and Alexander-Williams, J. In press. Alexander-Williams, J (i969) in After Vagotomy ed. J Alexander-Williams and A G Cox. London, Butterworth. Nyhus, L M (1962) in Surgery of the Stomach and Duodenum ed. H N Harkins and L. M Nyhus. Boston, Little, Brown. Beal, J Mf (I959) American Surgeon, 25, i. Herrington, J L (I962) in Surgery of the Stomach and Duodenum ed. H N Harkins and L, M Nyhus. Boston, Little, Brown. Faucet, A N, Johnston, D, and Duthie, H L (1969) British Journal of Surgery, 56, iii.

Assessment and treatment of recurrent peptic ulceration.

From the experience of treating 91 patients with a proven recurrent ulcer we consider that if a proven ulcer is shown to be present and a gastrin-secr...
720KB Sizes 0 Downloads 0 Views