Evaluation of Recurrent Duodenal Ulcer after Vagotomy-Pyloroplasty George L. Juier, MD, Long Beach, Angelo E. Dagradi,
California
MD, Long Beach,
Stephen J. Stemplen,
MD, Irvine,
Robert C. Combs, MD, Irvine,
California
California
California
Although vagotomy-pyloroplasty (V-P) has become an accepted method for treating the complications of duodenal ulcer [I-3], multiple studies have reported recurrence rates of 3.3 to 40.0 per cent after this procedure [Z-14]. A retrospective study was undertaken to determine why V-P failed to control the ulcer diathesis in patients in our hospital. Material
and Methods
The total number of operations for duodenal ulcer from 1950 to 1974 was obtained from the operating room log books. The charts of all patients who underwent a secondary operation for recurrent ulcer after vagotomy-gastroenterostomy (V-G) or vagotomy-pyloroplasty were reviewed for type of primary and secondary operations performed, indications for primary and secondary operation, interval between operations, evidence of persistent vagal innervation after primary operation, and presence of intact vagal trunks at reoperation. Insulin and tolbutamide studies were the basis for determining vagal innervation. From 1950 to 1974, 1,515 vagotomy and drainage procedures were performed as the primary operation for duodenal ulcer at the Veterans Administration Hospital, Long Reach. (Table I.) The types of drainage procedures employed are shown in Table II. The Heineke-Mikulicz pyloroplasty has been the standard drainage procedure. It was employed in 66.3 per cent of operations. Posterior gastrojejunostomy was employed in the early years but has been infrequently performed during the past ten years. Since 1964 the Jaboulay procedure has been used with increasing frequency but comprises only 3.3 per cent of all drainage procedures for duodenal ulcer. Finney pyloroplasty and more recently anterior pyloromyectomy were performed in only 1 per cent of patients.
The indications for vagotomy and drainage at the primary operation are shown in Table III. Hemorrhage, recurrent bleeding, and obstruction were the primary indications in 65.5 per cent of cases. When more than one indication for surgery was present, the primary reason for operation was chosen. The secondary operations employed to treat recurrent. duodenal ulcer are shown in Table IV. Recurrence was treated by antrectomy in seventy-five patients or 5 per cent of all patients treated surgically for duodenal ulcer. Thirteen of the patients treated by V-G were converted to V-P because of poorly functionie stomas or the afferent loop syndrome. Eighteen patients underwent completion TABLE I
Total Number of Operations for Duodenal Ulcer
Year 1950-1963 1964-l 974
Total
115 15
896 489
1011 504
1385
1515 __.
TABLE I I Types of Drainage Procedures -_ ---No. of Cases Procedure 1.307
Heineke-Mikulcz
-
._--
Per Cent (86.3%)
pyloroplasty Gastrojejunostomy Jaboulay procedure Finney pyloroplasty Anterior pyloromyectomy Total
TABLE iii -~
~
.-.--
Obstruction Perforation Intractability Total
-.. -._-
130 48 15 15 1,515
indications for Vagotomy Primary Operation
-.- .--.
Acute hemorrhage Recurrent bleeding
From the Veterans AdminIstratIonHospital,LongBeach. and lhe Departments of Surgeryand Gastroenterology,Universityof Californiaat Irvine.
volume 132, Aqfurt 1976
VIP
130
Total --.-_-_.__-
Indication
Irvine, California. Reprint requests shod be adhssed lo Gewge L. Juk. MD. 5901 E. 7lh Street. Long Beach, California 90822. Presented at the Forty-Seventh Annuel Meeting of the Pacific Coast Surgical Association. Monterey. California, February 15-16, 1976.
V/G
--
(100.0%) --.-
and Drainage at
.-.. -
No. of Cases 271 255 467 233 289 1,515
(8.5%) (3.2%) (1.0%) (1.0%)
_ -__-Per Cent (17.9%) (16.8%) (30.8%) (15.4%)
(19.1%) (100.0%) - ..- .- -_
243
Juler el al
TABLE __----
IV
Secondary
Operations --. --
Operation
.---.
for Duodenal No. of Cases
Antrectomy After V-P After V-G Conversion of V-G to V-P Completion of vagotomy
75 44 31 13 18
Total
TABLE V
Per Cent .-____ (5.0%) (3.0%) (2.0%) (0.8%)
(1.1%) (6.9%)
106
Indications for Secondary Operation after Vagotomy and Drainage
Indication
No. of V-P Cases
No. of V-G Cases
Hemorrhage Recurrent bleeding Obstruction Intractability Total
8 5 10 21 44
0 4 12 15 31
TABLE VI
Interval between Primary and Secondary Operations for Recurrent Ulcers
Operation Antrectomy Antrectomy Total
TABLE VII
Operation After V-P After V-G Total
TABLE VIII
Operative Findings Recurrent ulcer No ulcer Tota I
244
Ulcer
after after
Less than 5 Years
Greater than 5 Years
21 31 52
10 13 23
V-G V-P
Correlation between Proved Recurrent Ulcer and Preoperative Acid Secretion Tests Number of Recurrent Number of Tests Orodenal Performed Ulcers 28 17 45
Number of Positive Tests
25 17 42
23 (82.0%) 15 (88.0%) 38 (84.4%)
Correlation between Acid Secretory Tests and Intact Vagal Trunks at Revagotomy
Number of Patients
Number Number of with Nuinber Positive Intact Tested Tests Trunks
28
25
23
20
8 36
8 33
2 25
2 22
of the vagotomy; eight of these eventually had an antrectomy. The overall reoperation rate was 6.9 per cent after 1,509 truncal and six selective vagotomy and drainage procedures. The indications for secondary operation after vagotomy and drainage procedures are shown in Table V. Of the total seventy-five patients, intractability was the most frequent indication, followed by obstruction, recurrent bleeding, and hemorrhage. Of the eight patients who required antrectomy for uncontrolled hemorrhage following V-P, two died from vasculitis of the gastric or duodenal mucosa, four died from hemorrhagic erosive gastritis, and two died from uncontrolled bleeding from their duodenal ulcer. Of thirty-one patients with antrectomy after V-G had been performed as the primary operation for duodenal ulcer, seventeen were found to have recurrent ulceration at the second operation. Insulin or tolbutamide test [I51 for vagal innervation was positive in fifteen of the seventeen patients with recurrent ulcers. The remaining fourteen of the thirty-one patients were found to have either a narrow stoma or an afferent loop syndrome. Recurrent ulceration developed early in patients with V-P, whereas those with V-G tended to go longer before recurrence. (Table VI.) Seventy per cent of all secondary operations were within five years of the primary operation. Eighty-four per cent of all patients with proved recurrent ulceration had indications of an incomplete vagotomy by either an insulin or tolbutamide test. (Table VII.) Because there was an inadequate search for vagal trunks in fifteen of the patients treated by antrectomy after primary V-G, it was impossible to include the V-G patients in the correlation between a positive preoperative test for vagal innervation and presence of vagal fibers found at reoperation. However, in those patients treated by V-P, it was possible to establish a correlation between the presence of intact vagal trunks at reoperation and the presence of a positive insulin test prior to the second operation. (Table VIII). Twenty-three of twenty-five patients were found to have positive insulin or tolbutamide tests according to the criteria and interpretation of Stempien, Lee, and Dagradi [Is]. Twenty-two of these patients were found to have intact vagal trunks or fibers at reoperation. There was one patient who had a negative acid test and negative search for vagal fibers with documented recurrent ulcer. Eight patients without recurrent ulcer at reoperation had inadequate search for vagal trunks. Ten patients treated by Heineke-Mikulicz pyloroplasty had delayed emptying associated with recurrent ulcer. Comments The main criticism of V-P has been the relatively high incidence of recurrent ulceration [12]. Con-
trolled studies (1,~@-IO] have reported recurrence rates of 3.3 to 10.0 per cent after follow-up of five years or more. A report from our hospital [14] indicated that after ten years the recurrence rate was 40 per cent in the service-connected veteran and 18 per cent in the nonservice-connected veteran. Because The4Amorlcrn Jcurnal cl Surgwy
Duodenal
of the transient nature of our patient population we have 76.6 per cent follow-up at one year and only 52.3 per cent at ten years. Overall, intractable ulcer symptoms were the most common indication for reoperation, although after ten years bleeding became the most common indication. (Table V.) Others have reported a similar experience [7,12,13]. 1nadequat.e gastric emptying after V-P has been incriminated as a cause of recurrent ulceration by some authors [IS] even though Donovan, Alexander-Williams, and Clark (171 have reported that rapid gastric emptying is more common after V-P than after vagotomy-antrectomy (V-A). Farris, commenting in the report of Hoerr and Ward (121, believes that delayed emptying and not incomplete vagotomy is the reason for recurrent ulcers. In our group of forty-four patients who came to antrectomy after V-P (Table V), ten had delayed emptying on preoperative studies. Three of these patients were found to have angulation of the gastric outlet by ulceration into the liver and the others were obstructed by recurrent ulcers at the pyloroplasty. We now use the Jaboulay procedure if there is significant narrowing of the duodenum at the apex of the bulb or for postbulbar ulcers. We have performed forty-eight Jabouiay procedures over the past ten years (Table II) without recurrence of ulcer of significant sequelae. Recurrent ulceration has also been attributed to an incomplete vagotomy [2,9]. The positive correlation between an incomplete vagotomy and recurrent ulcer has been shown in several studies [18-231. The incidence of postoperative positive insulin tests has been reported to range from 37 to 47 per cent [11,18,19]. Several investigators have emphasized that gastric secretory tests performed within six months of operation are unreliable methods for predicting recurrent ulceration (I&?-20,221.However, Kennedy et al [3] believe that immediate postoperative secretory tests have merit, since their data show a clear correlation between positive early tests and recurrent ulcer. Johnston et al [19] reported that 68 per cent of patients who were found to have a positive acid secretory test early postoperatively had recurrent ulcers, whereas only 24 per cent of those with positive late tests did so. Other investigators [7,24] have found no correlation between acid secretory tests and recurrent ulceration and believe the test is too sensitive for vagal activity, since a duodenal ulcer is often controlled in the presence of an incomplete vagotomy. In our study 84.4 per cent of patients coming to antrectomy for recurrent ulcer after V-P had positive insulin or tolbutamide tests within five years of primary operation. (Table VIII.) Volume 132, Augusl 1876
Ulcer
A high incidence of intact vagal nerves has been found on reexploration of the esophageal hiatus. Kronborg (2.51reported that 19 of 27 patients with positive acid tests and five of seven patients wit.h negative tests had intact vagal trunks. Stuart and Hoerr [26] found that fifteen of forty-two patients at revagotomy had intact nerves. Similarly we found that twenty-two of twenty-eight patients (78.5 per cent) were noted to have intact vagal nerves at antrectomy and revagotomy. (Table VIII.) Fifteen of the vagal nerves were intact right posterior trunks, whereas seven were left anterior trunks or fibers. There was one patient in the study who had neither a positive acid test nor an intact vagal trunk who did have a recurrent ulcer at antrectomy. Two patients with recurrent ulcers had negative acid tests. Our attempt to control recurrent duodenal ulcer after V-P by revagotomy alone has been disappointing. Of the eighteen patients who had this procedure either through the abdomen or left chest, eight eventually came to antrectomy. Others [25,27,28] have also reported that vagotomy alone is less effective than vagotomy-antrectomy in controlling recurrent ulceration. We have concluded from this study that: (1) recurrent ulceration after V-P is associated with incomplete vagal section and a positive insulin or tolbutamide test; (2) failure of V-P to control the ulcer diathesis is a technical failure rather than a failure of the operative procedure itself; (3) the physiologic premise upon which the operation is based remains sound; and (4) the operation will control the ulcer symptoms in approximately 95 per cent of cases even though recurrence in elective cases may be 15 per cent. Summary
Seventy-five antrectomies were performed for recurrent duodenal ulcer after 1,515 vagotomy and drainage procedures. Eighty-four per cent of proved recurrences at reoperation were associated with positive acid secretory tests. Seventy-eight per cent of recurrences occurred in patients with intact vagal trunks. Incomplete vagotomy is implicated as the cause of recurrence. References 1. Thompson BW. Read IX: Long-term randomized prospective comparison of Finney and Helneke-Mikulkz pyboptasty In patients having vagotomy for peptic ulceration. Am J Surg 129: 70, 1975. 2. Gillett DJ, de Bu@ MM: Recurrent ulceration after gastroenterostoiny cf pyloroplasty with complete and incomplete vagotomy. Am J Sung 127: 650. 1974. 3. Kennedy F, MacKay C, Bedi BS, Kay AW: Truncal vagotomy
245
Juler et al
4. 5.
6.
7. 8.
9.
10.
11.
12.
13. 14.
15. 16.
17.
18. 19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
246
and drainage for dronic duodenal ulcer disease: a controlled trial. Br AM J 2: 71, 1973. Postlethwait RW: Five year follow-up results of operations for duodenal ulcer. Surg Gynecol Obstet 137: 387, 1973. Howard RJ, Murphy WR, Humphrey EW: A pospective randomized study of the elective surgical treatment for duodenal ulcer: two-to-ten-year follow-up study. Surgery 73: 256, 1973. Eisenberg MM, Woodard ER, Carson TJ, Dragstedt LR: Vagotomy and drainage for duodenal ulcer. Ann Surg 170: 317, 1969. Brooks JR. Kia D, Membreno AA: Truncal vagotomy and pyloroplasty for duodenal ulcer. Arch Surg 110: 822, 1975. Dwight RW. Schimmel EM, O’Hara ET, et al: Controlled study of the surgical treatment of duodenal ulcer. Am J Swg 129: 374, 1975. Goligher JC, Pulvertaft CN, Irvin TT, Johnston D. Walker B, Hall RA: Five-to-eight-year results of truncal vagotomy and pyloroplasty for duodenal ulcer. Br Mad J 1: 7, 1972. Jordan F+l Jr: A followup report of a prospective evaluation of vagotomy-pyloroplasty and vagotomy-antrectomy for treatment of duodenal ulcer. Ann Surg 180: 259, 1974. Judd DR, Starkloff GB, Morioka W, Quintero 0. Newton WT: Vagotomy and drainage procedure. Arch Surg 102: 242, 1971. l-berr SD, Ward JT: Late results of three operations for chronic duodenal ulcer: vagotomy-gastrojejunostomy. vagotomyhemigastrectomy, and vagotomy-pyloroplasty. Ann Surg 176: 403, 1972. Ahmad W, Harbrecht PJ: Recurrent duodenal ulcer disease. Arch Surg 108: 428. 1974. Stempien SJ, Dagradi AE, Lee ER, Simonton JH: Status of duodenal ulcer patients ten years or more after vagotomypyloroplasty (V&P). Am J Gastroenterol56: 99, 1971. Stempien SJ. Lee ER, Dagradi AE: Clinical appraisal of Insulin as gastric analysis. Am J Dig Dis 13: 21, 1968. Hines JR, Geurkink RE, Kornmesser TA, Wikholm L. Davis RP: Vagotomy and double pyloroplasty for pe@tic ulcer. Ann Swg 181: 40. 1975. Donovan IA, Alex--Williams J, Clark RJ: A comparison of gastrii emptying before and after vagotomy with tiectomy and vagotomy with pyloroplasty. Surgery 76: 729, 1974. Ross B, Kay AW: Insulin test after vagotcmy. Gsstfoenterology 46: 379, 1964. Johnston D, Thomas DG, Checketts RG, Duthie l-N: An assessment of postoperative testing for completeness of vagotomy. BrJSurg54: 031, 1967. Watkins D, Duthie HL: Changes in postoperative insulin test in relation to recurrent duodenal ulceration. Gut 12: 303, 1971. Kronbcfg 0: Gastric acid secretion and risk of recurrence of duodenal ulcer within six to eight years after truncal vagotomy and dralnage. Gut 15: 714, 1974. Cowley DJ, Spencer J, Baron JH: Acid secretion in relation to recurrence of duodenal ulcer after vagotomy and drainage. Br J Surg 60: 517, 1973. Burdette WJ, Rasmussen BL, Fitzpatrick WK Jr: Management of duodenal ulcer by vagus resection and pyloroplasty. Swg Gynecol Obstet 127: 513, 1968. Thompson BW, Read RC: Clinical significance of the positive response to the Hollander test. Am J Surg 120: 660, 1970. Kronbwg 0: A follow-up of patients operated upon for recurrence after vagotomy and drainage for duodenal ulcer. scend J Gastroentefol8: 123, 1973. Stuart M, Hoerr SO: Recurrent peptic ulcer following primary operation with vagotomy for duodenal ulcer. Arch Surg 103: 129,197l. Fawcett AN, Johnston D, Duthie l-U_:Revagotomy for recurent ulcer after vagotomy and drainage for duodenal ulcer. 8r J Surg56: 111, 1969. Jaffe BM. Newton WT, Judd DR: Surgical management of recurrent peptic ulcers. Am J Surg 117: 214. 1969.
Discussion Jack M. Farris (San Diego, CA): Recurrent ulceration after any definitive operation for duodenal ulcer is always a disappointment to surgeon and patient alike. Furthermore, it is invariably associated with undesirable and persistent hypersecretion of gastric juice. This phenomenon may be due to one of two different mechanisms. One is central in origin-a cephalic or neuromechanism mediated from specialized areas in the brain through vagus pathways that have been incompletely divided. The second is of antral origin-a hormonal mechanism related to secretion of measurable elevated serum gastrin levels, usually due to antral stimulation as a result of a pyloroplasty that does not empty well. With a patient with recurrent ulceration, however, incomplete vagotomy should probably be suspected until proved otherwise. Incomplete vagotomy is admittedly a technical error and obviously will occur more regularly in the hands of the inexperienced or unskilled surgeon or in patients of undesirable habitus. Theoretically, it should be correctible by finding a persistent fiber or fibers and dividing them and then nothing else. However, in the authors’ series, antrectomy was invariably added. A second anatomic approach is obviously preferable through the chest; if the problem is clearly related to incomplete vagotomy and not to emptying problems, this would be the approach of choice. I strongly urge all trainees who are interested in this operation to acquire extra surgical experience, in the autopsy room, beginning with transthoracic vagotomy and then practicing the same operation by the abdominal route. In our experience, long segments of nerves are removedsometimes 5 or 6 cm-and if a silver clip is placed on the cut proximal end, a postoperative roentgenogram will show the silver clips to be well up into the mediastinum. SO actually the same segments have been removed as if the transthoracic route had been employed. As a final maneuver, the fingers completely encircle the esophagus and all visible small fibers within the wall are divided under direct vision. When the operation is performed in this manner, I am confident that a surgeon making a second approach on the same patient will be disappointed in an attempt to find further nerve tissue. Furthermore, it is probably true that complete vagotomy in man is an impossibility and that no matter how carefully the nerves on the external wall of the esophagus are removed, a cross section of the esophagus will show smalI nerve fibers within the wall itself. Our experience at the University of California in San Diego now includes nearly 1,000 operations for benign lesions of the duodenum and stomach (mostly V-P for duodenal ulcer), our initial experience with this operation having begun in 1950. From this experience I have an increasing conviction that a significant percentage of the difficulties responsible for recurrent ulcers that we encounter are the result of a poorly emptying pyloroplasty and may mistakenly be thought to be due to incomplete vagotomy because of false-positive acid secretory studies. Allow me to develop this point fur-
TM Amerkan Journal of Sur~~t’y
Duodenal Ulcer
ther by showing specimens of vagus nerves removed through the chest from a patient thought to have had incomplete vagotomy. Despite the fact that large segments are removed, the patient’s secretory studies remained high and he was not relieved of his symptoms until the antrum was removed through the abdominal route. The transthoracic route is a notoriously elegant and foolproof technic for removing long segments of vagus nerves in man, and if one has complete confidence that the patient’s postoperative recurrent ulcer is clearly related to incomplete vagotomy, then this is certainly the method of choice. However, if this supposition proves to be incorrect, the abdominal approach is infinitely better so that there is an opportunity to search for other causes of recurrent ulcers such as the Zollinger-Ellison syndrome, enteroenterostomy producing a Mann-Williamson phenomenon, or retained antrum. Also, the important opportunity for antrectomy or revision of the pyloroplasty is forfeited when the transthoracic route is chosen. Recurrent ulceration after V-P may be due to antral stasis or to incomplete vagotomy, but the two may be indistinguishable by the ordinary acid secretory studies such as the Hollander test or by the usual gastrointestinal x-ray films. One therefore searches for persistent or overlooked nerves that may or may not be found and performs an antrectomy, thereby relieving the occult obstruction, and almost without exception this patient is permanently relieved of his undesirable symptoms. The third operation is almost unheard of after V-P. Hypersecretion which was present was therefore due to antral stasis and produced false-positive Hollander test results and is ultimately entered into the record book as an incomplete vagotomy. It is possible that a number of the authors’ patients may belong in this particular category. We no longer rely on the accuracy of the Hollander test and rarely use it. For the past eight or ten years, we have routinely employed the Jaboulay pyloroplasty (a lateral gastroduodenostomy) with an anastomosis of large size, which is in proximity to the ampulla of Vater. This anatomic arrangement provides obligatory neutralization of any persist&t hypersecretion if it should exist. Such pyloroplasties empty much better and secondary operations are rarely necessary. In our series, forty-eight patients have received this operation and not one thus far has required the operation. In more than 100 personal patients-some have now been observed for ten postoperative years-we have observed only one recurrence and this operation I predict may prove to be the operation of choice and also will prove to be competitive with the recurrence rate reported elsewhere for V-P. I hasten to add any difference in opinion is obviously a friendly one without which these meetings and discussions would become meaningless.
Victor Richards (San Francisco, CA): The authors’ recurrence rate was approximately 12 per cent. If you calculate from the follow-up, which was incomplete, it might come out as high as 18 to 20 per cent after V-P. That corresponds with my own belief about that is a good operation, but I think the recurrence rate is quite high.
Volume 132, Am
1976
Secondly, with respect to the Hollander test, we have not done this because there have been many recorded series in the literature in which the incidence of a positive Hollander test is 50 per cent, and it seems to have little correlation with the operation or whether the vagus nerves have been completely sectioned or not. The vagus nerves should be studied histologically to be certain of their removal, preferably by frozen section. Dragstedt, in his initial series of vagotomy, had something like 15 per cent recurrent gastric ulcers after V-P alone or V-G. He attributed this to improper emptying of the antrum and came up with the theory that gastric ulcers are of antral origin, whereas duodenal ulcers are not. I am surprised the authors did not have a higher incidence of recurrent gastric ulcers. I think it emphasizes again that we need a better test for the completeness of vagotomy. An interesting paper presented earlier was on the use of Congo Red test to establish completeness of vagotomy (see page 144). It would be nice to have a simple test for completeness of the vagotomy in the operating room. Another thought that occurred to me after reading this manuscript was that maybe all ulcers are not of similar origin. Surgeons studying gastrin and serum pepsinogen, which we can measure finally in ulcer patients, are pointing out that there may be great differences in ulcer patients as to the type of gastrin producing their ulcer, whether they have serum pepsinogen or not, and whether they have abnormal sensitivities to these. I think all of these problems are going to have to be evaluated prospectively in a group of ulcer patients, to let us decide what we are really talking about when we talk about “the ulcer patient.” There may be entirely different groups of ulcer patients, and one may do better with one type of operation than with another. Another important lesson in this paper is the fact that revagotomy alone does not solve the problem. I think the authors had eighteen patients with revagotomy alone, and of those, twelve had to be reoperated on because the vagotomy alone did not solve the ulcer problems. That has also been true in my experience. It would appear that V-A is the best single operation at the present time for these difficult cases. If a patient has had V-G or V-P, then probably resection of the antrum is the best operation we have at the present time. I hope Doctor Juler will take advantage of this tremendous amount of interesting material and, perhaps in association with other VA Hospitals, will conduct a prospective study about these ulcer factors-the vagus, the various kinds of ,gastrin, and the various kinds of serum pepsinogen in ulcer patients-and hopefully put it into a computer so we will have the information easily available when we want to get to it. Then, through the years, we will be able to answer some of the perplexing questions in the surgical treatment of ulcer patients. R. Cameron Harrison (Vancouver, British Columbia): The late Doctor Holubitsky and Doctors Johnson, Cleator and I reported the Vancouver experience in Ann Surg 179: 339,1974 and we have some more recent data. (Slide) We have forty-three patients with stomal ulcer after vagotomy
247
Juler et al
and drainage. The options, of course, are revagotomy and antrectomy, revagotomy alone, partial gastrectomy or antrectomy (which to us is the same operation), or conservative management. The most important thing is mortality, but recurrence is almost as important. We think the Hollander test is worth doing, but if it proves negative, the patient should have another and probably a third test before it is assumed negative, as it is a very uncommon finding after vagotomy when there is recurrent ulceration. If it is negative, there should be a stimulation test with histalog. Some of these patients have a very low secretion and they should not necessarily have further surgery. They should all, of course, have serum gastrin tests, endoscopy, and x-ray films. At reoperation, if the search for a vagal trunk is fruitful, this should probably suffice, although, as Doctor Farris noted, the recurrence rate with revagotomy alone in our experience and in the literature is disturbingly high (26 per cent). The addition of antrectomy will undoubtedly reduce the re-recurrence rate, but it will add to the mortality. This is particularly true if the primary drainage operation has been pyloroplasty rather than gastroenterostomy. Mortality with resection when pyloroplasty has been the primary drainage operation is double that after gastroenterostomy, and this is not surprising, particularly with a Jaboulay or more complicated type of pyloroplasty. We think, then, that one should individualize the situation, and”if at operation a revagotomy attempt is not fruitful, one should proceed to antrectomy. Were the three negative Hollander tests repeated more than once? Did you modify your procedure in any way, depending on the intraoperative findings, and do you modify it with respect to whether the primary drainage operation has been pyloroplasty or gastroenterostomy? Finally, Xwas not sure from your presentation what the mortality was after antrectomy, and whether or not the primary drainage operation influenced this? Thomas T. White (Seattle, WA): I am somewhat confused by the authors’ report. Did you mean to say that you only recommend V-P for acute bIeeding, obstruction, or perforation, because you stated that there is a much higher recurrence rate in the elective cases than in the acute cases? A previous report from the Medical Service at your hospital stated that there was a 28 per cent recurrence rate after V-P. For this reason I wonder whether or not you really prefer V-A in the elective cases instead. Does a recent review of the literature indicating an average recurrence rate of 25 per cent after V-P influence you to perform antrectomy instead? I am confused to hear different recurrence rates from the same hospital. Meredith Smith (Seattle, WA): Although the authors did not mention it, I wonder if they noticed a decline in the number of duodenal ulcer operations performed during the period of their study. In Seattle, we have noticed a marked decline in the number of duodenal ulcer operations, presumably because of the decline in the incidence of du-
248
odenal ulcers. To verify this, we reviewed the number of primary duodenal ulcer operations and primary duodenal ulcer perforations in a ten year period in two downtown hospitals, two suburban hospitals, and the VA Hospital. The decline is impressive. In the first five year period, we had some 700 primary operations for duodenal ulcer, either vagotomy, gastrectomy, or a combination of the two. In the second five year period, less than 509 were performed, indicating a decline of 35 per cent. Almost the same figures were found in the suburban hospitals as in the downtown hospitals and the VA Hospital. Does this mean we are getting more sophisticated in operating on less duodenal ulcers? It does not seem so, because the medical community in Seattle has been conservative and stable for many years. We checked the incidence of duodenal ulcer by studying the number of perforations at the same hospitals. Perforations probably represent a fixed percentage of primary duodenal ulcer, albeit 7 to 12 per cent. That incidence declined about the same percentage as the number of duodenal ulcer operations-approximately 36 per cent. This decline in the incidence of duodenal ulcer was first noticed in England since 1955. So, duodenal ulcer disease, which started from almost nothing around 1880 or 1890, increased like a rocket to about 1955, peaked out, and has been declining for twenty years. Why? The doors are open for all sorts of speculation. Perhaps the decline is due to the adjustment of modern man to urbanization. It is an interesting phenomenon, and I think, in the future, it will be mentioned in reviews of ulcer such as this one. Robert C. Combs (closing): This study was brought about because Doctor Joseph Weinberg called Doctor Juler some time ago and suggested that our data be made current. In reviewing our material and the literature we find two features woven in and out of all considerations of recurrent ulcer. These are incomplete vagotomy and poor drainage. We get the impression that each of the operations favored by one group or another in the world is an adequate operation, and maybe the difficulties come about because the operations are done inadequately by surgeons. Poor results are obtained at times because the surgeon hurries, does not perform a complete vagotomy, or tailors an anastomosis with which he is not completely satisfied. We were delighted with the paper of Saik et al on the use of Congo Red presented earlier. I am sure we will consider using the Congo Red test at the VA Hospital in Long Beach. We have not heretofore. Doctor Richards asked about frozen sections. We do use frozen sections at surgery. We have had six recurrent gastric ulcers, but most of those were associated with duodenal or stoma1 ulcers. The challenging thought of conducting a prospective study is one which I think we cannot ignore. We did repeat the Hollander test. We do not assume that any one test is adequate. We do not advocate V-A as a primary operation for duodenal ulcer electively but prefer vagotomy and some sort of pyloroplasty. Our mortality with V-A is approximately 1.5 per cent, and with V-P 0.5 per cent.
The Amerkan Jwrnald
Surgery
California
MD, Long Beach,
Stephen J. Stemplen,
MD, Irvine,
Robert C. Combs, MD, Irvine,
California
California
California
Although vagotomy-pyloroplasty (V-P) has become an accepted method for treating the complications of duodenal ulcer [I-3], multiple studies have reported recurrence rates of 3.3 to 40.0 per cent after this procedure [Z-14]. A retrospective study was undertaken to determine why V-P failed to control the ulcer diathesis in patients in our hospital. Material
and Methods
The total number of operations for duodenal ulcer from 1950 to 1974 was obtained from the operating room log books. The charts of all patients who underwent a secondary operation for recurrent ulcer after vagotomy-gastroenterostomy (V-G) or vagotomy-pyloroplasty were reviewed for type of primary and secondary operations performed, indications for primary and secondary operation, interval between operations, evidence of persistent vagal innervation after primary operation, and presence of intact vagal trunks at reoperation. Insulin and tolbutamide studies were the basis for determining vagal innervation. From 1950 to 1974, 1,515 vagotomy and drainage procedures were performed as the primary operation for duodenal ulcer at the Veterans Administration Hospital, Long Reach. (Table I.) The types of drainage procedures employed are shown in Table II. The Heineke-Mikulicz pyloroplasty has been the standard drainage procedure. It was employed in 66.3 per cent of operations. Posterior gastrojejunostomy was employed in the early years but has been infrequently performed during the past ten years. Since 1964 the Jaboulay procedure has been used with increasing frequency but comprises only 3.3 per cent of all drainage procedures for duodenal ulcer. Finney pyloroplasty and more recently anterior pyloromyectomy were performed in only 1 per cent of patients.
The indications for vagotomy and drainage at the primary operation are shown in Table III. Hemorrhage, recurrent bleeding, and obstruction were the primary indications in 65.5 per cent of cases. When more than one indication for surgery was present, the primary reason for operation was chosen. The secondary operations employed to treat recurrent. duodenal ulcer are shown in Table IV. Recurrence was treated by antrectomy in seventy-five patients or 5 per cent of all patients treated surgically for duodenal ulcer. Thirteen of the patients treated by V-G were converted to V-P because of poorly functionie stomas or the afferent loop syndrome. Eighteen patients underwent completion TABLE I
Total Number of Operations for Duodenal Ulcer
Year 1950-1963 1964-l 974
Total
115 15
896 489
1011 504
1385
1515 __.
TABLE I I Types of Drainage Procedures -_ ---No. of Cases Procedure 1.307
Heineke-Mikulcz
-
._--
Per Cent (86.3%)
pyloroplasty Gastrojejunostomy Jaboulay procedure Finney pyloroplasty Anterior pyloromyectomy Total
TABLE iii -~
~
.-.--
Obstruction Perforation Intractability Total
-.. -._-
130 48 15 15 1,515
indications for Vagotomy Primary Operation
-.- .--.
Acute hemorrhage Recurrent bleeding
From the Veterans AdminIstratIonHospital,LongBeach. and lhe Departments of Surgeryand Gastroenterology,Universityof Californiaat Irvine.
volume 132, Aqfurt 1976
VIP
130
Total --.-_-_.__-
Indication
Irvine, California. Reprint requests shod be adhssed lo Gewge L. Juk. MD. 5901 E. 7lh Street. Long Beach, California 90822. Presented at the Forty-Seventh Annuel Meeting of the Pacific Coast Surgical Association. Monterey. California, February 15-16, 1976.
V/G
--
(100.0%) --.-
and Drainage at
.-.. -
No. of Cases 271 255 467 233 289 1,515
(8.5%) (3.2%) (1.0%) (1.0%)
_ -__-Per Cent (17.9%) (16.8%) (30.8%) (15.4%)
(19.1%) (100.0%) - ..- .- -_
243
Juler el al
TABLE __----
IV
Secondary
Operations --. --
Operation
.---.
for Duodenal No. of Cases
Antrectomy After V-P After V-G Conversion of V-G to V-P Completion of vagotomy
75 44 31 13 18
Total
TABLE V
Per Cent .-____ (5.0%) (3.0%) (2.0%) (0.8%)
(1.1%) (6.9%)
106
Indications for Secondary Operation after Vagotomy and Drainage
Indication
No. of V-P Cases
No. of V-G Cases
Hemorrhage Recurrent bleeding Obstruction Intractability Total
8 5 10 21 44
0 4 12 15 31
TABLE VI
Interval between Primary and Secondary Operations for Recurrent Ulcers
Operation Antrectomy Antrectomy Total
TABLE VII
Operation After V-P After V-G Total
TABLE VIII
Operative Findings Recurrent ulcer No ulcer Tota I
244
Ulcer
after after
Less than 5 Years
Greater than 5 Years
21 31 52
10 13 23
V-G V-P
Correlation between Proved Recurrent Ulcer and Preoperative Acid Secretion Tests Number of Recurrent Number of Tests Orodenal Performed Ulcers 28 17 45
Number of Positive Tests
25 17 42
23 (82.0%) 15 (88.0%) 38 (84.4%)
Correlation between Acid Secretory Tests and Intact Vagal Trunks at Revagotomy
Number of Patients
Number Number of with Nuinber Positive Intact Tested Tests Trunks
28
25
23
20
8 36
8 33
2 25
2 22
of the vagotomy; eight of these eventually had an antrectomy. The overall reoperation rate was 6.9 per cent after 1,509 truncal and six selective vagotomy and drainage procedures. The indications for secondary operation after vagotomy and drainage procedures are shown in Table V. Of the total seventy-five patients, intractability was the most frequent indication, followed by obstruction, recurrent bleeding, and hemorrhage. Of the eight patients who required antrectomy for uncontrolled hemorrhage following V-P, two died from vasculitis of the gastric or duodenal mucosa, four died from hemorrhagic erosive gastritis, and two died from uncontrolled bleeding from their duodenal ulcer. Of thirty-one patients with antrectomy after V-G had been performed as the primary operation for duodenal ulcer, seventeen were found to have recurrent ulceration at the second operation. Insulin or tolbutamide test [I51 for vagal innervation was positive in fifteen of the seventeen patients with recurrent ulcers. The remaining fourteen of the thirty-one patients were found to have either a narrow stoma or an afferent loop syndrome. Recurrent ulceration developed early in patients with V-P, whereas those with V-G tended to go longer before recurrence. (Table VI.) Seventy per cent of all secondary operations were within five years of the primary operation. Eighty-four per cent of all patients with proved recurrent ulceration had indications of an incomplete vagotomy by either an insulin or tolbutamide test. (Table VII.) Because there was an inadequate search for vagal trunks in fifteen of the patients treated by antrectomy after primary V-G, it was impossible to include the V-G patients in the correlation between a positive preoperative test for vagal innervation and presence of vagal fibers found at reoperation. However, in those patients treated by V-P, it was possible to establish a correlation between the presence of intact vagal trunks at reoperation and the presence of a positive insulin test prior to the second operation. (Table VIII). Twenty-three of twenty-five patients were found to have positive insulin or tolbutamide tests according to the criteria and interpretation of Stempien, Lee, and Dagradi [Is]. Twenty-two of these patients were found to have intact vagal trunks or fibers at reoperation. There was one patient who had a negative acid test and negative search for vagal fibers with documented recurrent ulcer. Eight patients without recurrent ulcer at reoperation had inadequate search for vagal trunks. Ten patients treated by Heineke-Mikulicz pyloroplasty had delayed emptying associated with recurrent ulcer. Comments The main criticism of V-P has been the relatively high incidence of recurrent ulceration [12]. Con-
trolled studies (1,~@-IO] have reported recurrence rates of 3.3 to 10.0 per cent after follow-up of five years or more. A report from our hospital [14] indicated that after ten years the recurrence rate was 40 per cent in the service-connected veteran and 18 per cent in the nonservice-connected veteran. Because The4Amorlcrn Jcurnal cl Surgwy
Duodenal
of the transient nature of our patient population we have 76.6 per cent follow-up at one year and only 52.3 per cent at ten years. Overall, intractable ulcer symptoms were the most common indication for reoperation, although after ten years bleeding became the most common indication. (Table V.) Others have reported a similar experience [7,12,13]. 1nadequat.e gastric emptying after V-P has been incriminated as a cause of recurrent ulceration by some authors [IS] even though Donovan, Alexander-Williams, and Clark (171 have reported that rapid gastric emptying is more common after V-P than after vagotomy-antrectomy (V-A). Farris, commenting in the report of Hoerr and Ward (121, believes that delayed emptying and not incomplete vagotomy is the reason for recurrent ulcers. In our group of forty-four patients who came to antrectomy after V-P (Table V), ten had delayed emptying on preoperative studies. Three of these patients were found to have angulation of the gastric outlet by ulceration into the liver and the others were obstructed by recurrent ulcers at the pyloroplasty. We now use the Jaboulay procedure if there is significant narrowing of the duodenum at the apex of the bulb or for postbulbar ulcers. We have performed forty-eight Jabouiay procedures over the past ten years (Table II) without recurrence of ulcer of significant sequelae. Recurrent ulceration has also been attributed to an incomplete vagotomy [2,9]. The positive correlation between an incomplete vagotomy and recurrent ulcer has been shown in several studies [18-231. The incidence of postoperative positive insulin tests has been reported to range from 37 to 47 per cent [11,18,19]. Several investigators have emphasized that gastric secretory tests performed within six months of operation are unreliable methods for predicting recurrent ulceration (I&?-20,221.However, Kennedy et al [3] believe that immediate postoperative secretory tests have merit, since their data show a clear correlation between positive early tests and recurrent ulcer. Johnston et al [19] reported that 68 per cent of patients who were found to have a positive acid secretory test early postoperatively had recurrent ulcers, whereas only 24 per cent of those with positive late tests did so. Other investigators [7,24] have found no correlation between acid secretory tests and recurrent ulceration and believe the test is too sensitive for vagal activity, since a duodenal ulcer is often controlled in the presence of an incomplete vagotomy. In our study 84.4 per cent of patients coming to antrectomy for recurrent ulcer after V-P had positive insulin or tolbutamide tests within five years of primary operation. (Table VIII.) Volume 132, Augusl 1876
Ulcer
A high incidence of intact vagal nerves has been found on reexploration of the esophageal hiatus. Kronborg (2.51reported that 19 of 27 patients with positive acid tests and five of seven patients wit.h negative tests had intact vagal trunks. Stuart and Hoerr [26] found that fifteen of forty-two patients at revagotomy had intact nerves. Similarly we found that twenty-two of twenty-eight patients (78.5 per cent) were noted to have intact vagal nerves at antrectomy and revagotomy. (Table VIII.) Fifteen of the vagal nerves were intact right posterior trunks, whereas seven were left anterior trunks or fibers. There was one patient in the study who had neither a positive acid test nor an intact vagal trunk who did have a recurrent ulcer at antrectomy. Two patients with recurrent ulcers had negative acid tests. Our attempt to control recurrent duodenal ulcer after V-P by revagotomy alone has been disappointing. Of the eighteen patients who had this procedure either through the abdomen or left chest, eight eventually came to antrectomy. Others [25,27,28] have also reported that vagotomy alone is less effective than vagotomy-antrectomy in controlling recurrent ulceration. We have concluded from this study that: (1) recurrent ulceration after V-P is associated with incomplete vagal section and a positive insulin or tolbutamide test; (2) failure of V-P to control the ulcer diathesis is a technical failure rather than a failure of the operative procedure itself; (3) the physiologic premise upon which the operation is based remains sound; and (4) the operation will control the ulcer symptoms in approximately 95 per cent of cases even though recurrence in elective cases may be 15 per cent. Summary
Seventy-five antrectomies were performed for recurrent duodenal ulcer after 1,515 vagotomy and drainage procedures. Eighty-four per cent of proved recurrences at reoperation were associated with positive acid secretory tests. Seventy-eight per cent of recurrences occurred in patients with intact vagal trunks. Incomplete vagotomy is implicated as the cause of recurrence. References 1. Thompson BW. Read IX: Long-term randomized prospective comparison of Finney and Helneke-Mikulkz pyboptasty In patients having vagotomy for peptic ulceration. Am J Surg 129: 70, 1975. 2. Gillett DJ, de Bu@ MM: Recurrent ulceration after gastroenterostoiny cf pyloroplasty with complete and incomplete vagotomy. Am J Sung 127: 650. 1974. 3. Kennedy F, MacKay C, Bedi BS, Kay AW: Truncal vagotomy
245
Juler et al
4. 5.
6.
7. 8.
9.
10.
11.
12.
13. 14.
15. 16.
17.
18. 19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
246
and drainage for dronic duodenal ulcer disease: a controlled trial. Br AM J 2: 71, 1973. Postlethwait RW: Five year follow-up results of operations for duodenal ulcer. Surg Gynecol Obstet 137: 387, 1973. Howard RJ, Murphy WR, Humphrey EW: A pospective randomized study of the elective surgical treatment for duodenal ulcer: two-to-ten-year follow-up study. Surgery 73: 256, 1973. Eisenberg MM, Woodard ER, Carson TJ, Dragstedt LR: Vagotomy and drainage for duodenal ulcer. Ann Surg 170: 317, 1969. Brooks JR. Kia D, Membreno AA: Truncal vagotomy and pyloroplasty for duodenal ulcer. Arch Surg 110: 822, 1975. Dwight RW. Schimmel EM, O’Hara ET, et al: Controlled study of the surgical treatment of duodenal ulcer. Am J Swg 129: 374, 1975. Goligher JC, Pulvertaft CN, Irvin TT, Johnston D. Walker B, Hall RA: Five-to-eight-year results of truncal vagotomy and pyloroplasty for duodenal ulcer. Br Mad J 1: 7, 1972. Jordan F+l Jr: A followup report of a prospective evaluation of vagotomy-pyloroplasty and vagotomy-antrectomy for treatment of duodenal ulcer. Ann Surg 180: 259, 1974. Judd DR, Starkloff GB, Morioka W, Quintero 0. Newton WT: Vagotomy and drainage procedure. Arch Surg 102: 242, 1971. l-berr SD, Ward JT: Late results of three operations for chronic duodenal ulcer: vagotomy-gastrojejunostomy. vagotomyhemigastrectomy, and vagotomy-pyloroplasty. Ann Surg 176: 403, 1972. Ahmad W, Harbrecht PJ: Recurrent duodenal ulcer disease. Arch Surg 108: 428. 1974. Stempien SJ, Dagradi AE, Lee ER, Simonton JH: Status of duodenal ulcer patients ten years or more after vagotomypyloroplasty (V&P). Am J Gastroenterol56: 99, 1971. Stempien SJ. Lee ER, Dagradi AE: Clinical appraisal of Insulin as gastric analysis. Am J Dig Dis 13: 21, 1968. Hines JR, Geurkink RE, Kornmesser TA, Wikholm L. Davis RP: Vagotomy and double pyloroplasty for pe@tic ulcer. Ann Swg 181: 40. 1975. Donovan IA, Alex--Williams J, Clark RJ: A comparison of gastrii emptying before and after vagotomy with tiectomy and vagotomy with pyloroplasty. Surgery 76: 729, 1974. Ross B, Kay AW: Insulin test after vagotcmy. Gsstfoenterology 46: 379, 1964. Johnston D, Thomas DG, Checketts RG, Duthie l-N: An assessment of postoperative testing for completeness of vagotomy. BrJSurg54: 031, 1967. Watkins D, Duthie HL: Changes in postoperative insulin test in relation to recurrent duodenal ulceration. Gut 12: 303, 1971. Kronbcfg 0: Gastric acid secretion and risk of recurrence of duodenal ulcer within six to eight years after truncal vagotomy and dralnage. Gut 15: 714, 1974. Cowley DJ, Spencer J, Baron JH: Acid secretion in relation to recurrence of duodenal ulcer after vagotomy and drainage. Br J Surg 60: 517, 1973. Burdette WJ, Rasmussen BL, Fitzpatrick WK Jr: Management of duodenal ulcer by vagus resection and pyloroplasty. Swg Gynecol Obstet 127: 513, 1968. Thompson BW, Read RC: Clinical significance of the positive response to the Hollander test. Am J Surg 120: 660, 1970. Kronbwg 0: A follow-up of patients operated upon for recurrence after vagotomy and drainage for duodenal ulcer. scend J Gastroentefol8: 123, 1973. Stuart M, Hoerr SO: Recurrent peptic ulcer following primary operation with vagotomy for duodenal ulcer. Arch Surg 103: 129,197l. Fawcett AN, Johnston D, Duthie l-U_:Revagotomy for recurent ulcer after vagotomy and drainage for duodenal ulcer. 8r J Surg56: 111, 1969. Jaffe BM. Newton WT, Judd DR: Surgical management of recurrent peptic ulcers. Am J Surg 117: 214. 1969.
Discussion Jack M. Farris (San Diego, CA): Recurrent ulceration after any definitive operation for duodenal ulcer is always a disappointment to surgeon and patient alike. Furthermore, it is invariably associated with undesirable and persistent hypersecretion of gastric juice. This phenomenon may be due to one of two different mechanisms. One is central in origin-a cephalic or neuromechanism mediated from specialized areas in the brain through vagus pathways that have been incompletely divided. The second is of antral origin-a hormonal mechanism related to secretion of measurable elevated serum gastrin levels, usually due to antral stimulation as a result of a pyloroplasty that does not empty well. With a patient with recurrent ulceration, however, incomplete vagotomy should probably be suspected until proved otherwise. Incomplete vagotomy is admittedly a technical error and obviously will occur more regularly in the hands of the inexperienced or unskilled surgeon or in patients of undesirable habitus. Theoretically, it should be correctible by finding a persistent fiber or fibers and dividing them and then nothing else. However, in the authors’ series, antrectomy was invariably added. A second anatomic approach is obviously preferable through the chest; if the problem is clearly related to incomplete vagotomy and not to emptying problems, this would be the approach of choice. I strongly urge all trainees who are interested in this operation to acquire extra surgical experience, in the autopsy room, beginning with transthoracic vagotomy and then practicing the same operation by the abdominal route. In our experience, long segments of nerves are removedsometimes 5 or 6 cm-and if a silver clip is placed on the cut proximal end, a postoperative roentgenogram will show the silver clips to be well up into the mediastinum. SO actually the same segments have been removed as if the transthoracic route had been employed. As a final maneuver, the fingers completely encircle the esophagus and all visible small fibers within the wall are divided under direct vision. When the operation is performed in this manner, I am confident that a surgeon making a second approach on the same patient will be disappointed in an attempt to find further nerve tissue. Furthermore, it is probably true that complete vagotomy in man is an impossibility and that no matter how carefully the nerves on the external wall of the esophagus are removed, a cross section of the esophagus will show smalI nerve fibers within the wall itself. Our experience at the University of California in San Diego now includes nearly 1,000 operations for benign lesions of the duodenum and stomach (mostly V-P for duodenal ulcer), our initial experience with this operation having begun in 1950. From this experience I have an increasing conviction that a significant percentage of the difficulties responsible for recurrent ulcers that we encounter are the result of a poorly emptying pyloroplasty and may mistakenly be thought to be due to incomplete vagotomy because of false-positive acid secretory studies. Allow me to develop this point fur-
TM Amerkan Journal of Sur~~t’y
Duodenal Ulcer
ther by showing specimens of vagus nerves removed through the chest from a patient thought to have had incomplete vagotomy. Despite the fact that large segments are removed, the patient’s secretory studies remained high and he was not relieved of his symptoms until the antrum was removed through the abdominal route. The transthoracic route is a notoriously elegant and foolproof technic for removing long segments of vagus nerves in man, and if one has complete confidence that the patient’s postoperative recurrent ulcer is clearly related to incomplete vagotomy, then this is certainly the method of choice. However, if this supposition proves to be incorrect, the abdominal approach is infinitely better so that there is an opportunity to search for other causes of recurrent ulcers such as the Zollinger-Ellison syndrome, enteroenterostomy producing a Mann-Williamson phenomenon, or retained antrum. Also, the important opportunity for antrectomy or revision of the pyloroplasty is forfeited when the transthoracic route is chosen. Recurrent ulceration after V-P may be due to antral stasis or to incomplete vagotomy, but the two may be indistinguishable by the ordinary acid secretory studies such as the Hollander test or by the usual gastrointestinal x-ray films. One therefore searches for persistent or overlooked nerves that may or may not be found and performs an antrectomy, thereby relieving the occult obstruction, and almost without exception this patient is permanently relieved of his undesirable symptoms. The third operation is almost unheard of after V-P. Hypersecretion which was present was therefore due to antral stasis and produced false-positive Hollander test results and is ultimately entered into the record book as an incomplete vagotomy. It is possible that a number of the authors’ patients may belong in this particular category. We no longer rely on the accuracy of the Hollander test and rarely use it. For the past eight or ten years, we have routinely employed the Jaboulay pyloroplasty (a lateral gastroduodenostomy) with an anastomosis of large size, which is in proximity to the ampulla of Vater. This anatomic arrangement provides obligatory neutralization of any persist&t hypersecretion if it should exist. Such pyloroplasties empty much better and secondary operations are rarely necessary. In our series, forty-eight patients have received this operation and not one thus far has required the operation. In more than 100 personal patients-some have now been observed for ten postoperative years-we have observed only one recurrence and this operation I predict may prove to be the operation of choice and also will prove to be competitive with the recurrence rate reported elsewhere for V-P. I hasten to add any difference in opinion is obviously a friendly one without which these meetings and discussions would become meaningless.
Victor Richards (San Francisco, CA): The authors’ recurrence rate was approximately 12 per cent. If you calculate from the follow-up, which was incomplete, it might come out as high as 18 to 20 per cent after V-P. That corresponds with my own belief about that is a good operation, but I think the recurrence rate is quite high.
Volume 132, Am
1976
Secondly, with respect to the Hollander test, we have not done this because there have been many recorded series in the literature in which the incidence of a positive Hollander test is 50 per cent, and it seems to have little correlation with the operation or whether the vagus nerves have been completely sectioned or not. The vagus nerves should be studied histologically to be certain of their removal, preferably by frozen section. Dragstedt, in his initial series of vagotomy, had something like 15 per cent recurrent gastric ulcers after V-P alone or V-G. He attributed this to improper emptying of the antrum and came up with the theory that gastric ulcers are of antral origin, whereas duodenal ulcers are not. I am surprised the authors did not have a higher incidence of recurrent gastric ulcers. I think it emphasizes again that we need a better test for the completeness of vagotomy. An interesting paper presented earlier was on the use of Congo Red test to establish completeness of vagotomy (see page 144). It would be nice to have a simple test for completeness of the vagotomy in the operating room. Another thought that occurred to me after reading this manuscript was that maybe all ulcers are not of similar origin. Surgeons studying gastrin and serum pepsinogen, which we can measure finally in ulcer patients, are pointing out that there may be great differences in ulcer patients as to the type of gastrin producing their ulcer, whether they have serum pepsinogen or not, and whether they have abnormal sensitivities to these. I think all of these problems are going to have to be evaluated prospectively in a group of ulcer patients, to let us decide what we are really talking about when we talk about “the ulcer patient.” There may be entirely different groups of ulcer patients, and one may do better with one type of operation than with another. Another important lesson in this paper is the fact that revagotomy alone does not solve the problem. I think the authors had eighteen patients with revagotomy alone, and of those, twelve had to be reoperated on because the vagotomy alone did not solve the ulcer problems. That has also been true in my experience. It would appear that V-A is the best single operation at the present time for these difficult cases. If a patient has had V-G or V-P, then probably resection of the antrum is the best operation we have at the present time. I hope Doctor Juler will take advantage of this tremendous amount of interesting material and, perhaps in association with other VA Hospitals, will conduct a prospective study about these ulcer factors-the vagus, the various kinds of ,gastrin, and the various kinds of serum pepsinogen in ulcer patients-and hopefully put it into a computer so we will have the information easily available when we want to get to it. Then, through the years, we will be able to answer some of the perplexing questions in the surgical treatment of ulcer patients. R. Cameron Harrison (Vancouver, British Columbia): The late Doctor Holubitsky and Doctors Johnson, Cleator and I reported the Vancouver experience in Ann Surg 179: 339,1974 and we have some more recent data. (Slide) We have forty-three patients with stomal ulcer after vagotomy
247
Juler et al
and drainage. The options, of course, are revagotomy and antrectomy, revagotomy alone, partial gastrectomy or antrectomy (which to us is the same operation), or conservative management. The most important thing is mortality, but recurrence is almost as important. We think the Hollander test is worth doing, but if it proves negative, the patient should have another and probably a third test before it is assumed negative, as it is a very uncommon finding after vagotomy when there is recurrent ulceration. If it is negative, there should be a stimulation test with histalog. Some of these patients have a very low secretion and they should not necessarily have further surgery. They should all, of course, have serum gastrin tests, endoscopy, and x-ray films. At reoperation, if the search for a vagal trunk is fruitful, this should probably suffice, although, as Doctor Farris noted, the recurrence rate with revagotomy alone in our experience and in the literature is disturbingly high (26 per cent). The addition of antrectomy will undoubtedly reduce the re-recurrence rate, but it will add to the mortality. This is particularly true if the primary drainage operation has been pyloroplasty rather than gastroenterostomy. Mortality with resection when pyloroplasty has been the primary drainage operation is double that after gastroenterostomy, and this is not surprising, particularly with a Jaboulay or more complicated type of pyloroplasty. We think, then, that one should individualize the situation, and”if at operation a revagotomy attempt is not fruitful, one should proceed to antrectomy. Were the three negative Hollander tests repeated more than once? Did you modify your procedure in any way, depending on the intraoperative findings, and do you modify it with respect to whether the primary drainage operation has been pyloroplasty or gastroenterostomy? Finally, Xwas not sure from your presentation what the mortality was after antrectomy, and whether or not the primary drainage operation influenced this? Thomas T. White (Seattle, WA): I am somewhat confused by the authors’ report. Did you mean to say that you only recommend V-P for acute bIeeding, obstruction, or perforation, because you stated that there is a much higher recurrence rate in the elective cases than in the acute cases? A previous report from the Medical Service at your hospital stated that there was a 28 per cent recurrence rate after V-P. For this reason I wonder whether or not you really prefer V-A in the elective cases instead. Does a recent review of the literature indicating an average recurrence rate of 25 per cent after V-P influence you to perform antrectomy instead? I am confused to hear different recurrence rates from the same hospital. Meredith Smith (Seattle, WA): Although the authors did not mention it, I wonder if they noticed a decline in the number of duodenal ulcer operations performed during the period of their study. In Seattle, we have noticed a marked decline in the number of duodenal ulcer operations, presumably because of the decline in the incidence of du-
248
odenal ulcers. To verify this, we reviewed the number of primary duodenal ulcer operations and primary duodenal ulcer perforations in a ten year period in two downtown hospitals, two suburban hospitals, and the VA Hospital. The decline is impressive. In the first five year period, we had some 700 primary operations for duodenal ulcer, either vagotomy, gastrectomy, or a combination of the two. In the second five year period, less than 509 were performed, indicating a decline of 35 per cent. Almost the same figures were found in the suburban hospitals as in the downtown hospitals and the VA Hospital. Does this mean we are getting more sophisticated in operating on less duodenal ulcers? It does not seem so, because the medical community in Seattle has been conservative and stable for many years. We checked the incidence of duodenal ulcer by studying the number of perforations at the same hospitals. Perforations probably represent a fixed percentage of primary duodenal ulcer, albeit 7 to 12 per cent. That incidence declined about the same percentage as the number of duodenal ulcer operations-approximately 36 per cent. This decline in the incidence of duodenal ulcer was first noticed in England since 1955. So, duodenal ulcer disease, which started from almost nothing around 1880 or 1890, increased like a rocket to about 1955, peaked out, and has been declining for twenty years. Why? The doors are open for all sorts of speculation. Perhaps the decline is due to the adjustment of modern man to urbanization. It is an interesting phenomenon, and I think, in the future, it will be mentioned in reviews of ulcer such as this one. Robert C. Combs (closing): This study was brought about because Doctor Joseph Weinberg called Doctor Juler some time ago and suggested that our data be made current. In reviewing our material and the literature we find two features woven in and out of all considerations of recurrent ulcer. These are incomplete vagotomy and poor drainage. We get the impression that each of the operations favored by one group or another in the world is an adequate operation, and maybe the difficulties come about because the operations are done inadequately by surgeons. Poor results are obtained at times because the surgeon hurries, does not perform a complete vagotomy, or tailors an anastomosis with which he is not completely satisfied. We were delighted with the paper of Saik et al on the use of Congo Red presented earlier. I am sure we will consider using the Congo Red test at the VA Hospital in Long Beach. We have not heretofore. Doctor Richards asked about frozen sections. We do use frozen sections at surgery. We have had six recurrent gastric ulcers, but most of those were associated with duodenal or stoma1 ulcers. The challenging thought of conducting a prospective study is one which I think we cannot ignore. We did repeat the Hollander test. We do not assume that any one test is adequate. We do not advocate V-A as a primary operation for duodenal ulcer electively but prefer vagotomy and some sort of pyloroplasty. Our mortality with V-A is approximately 1.5 per cent, and with V-P 0.5 per cent.
The Amerkan Jwrnald
Surgery
