World J. Surg. 1, 493-499, 1977
---)~ ~~ p v B
9 1977 by the Soci6t~ Internationale de Chirurgie
ORIGINAL SCIENTIFIC REPORTS Operative Treatment of Recurrence after Vagotomy and Drainage for Duodenal Ulcer, Gastric Ulcer, and Acid Dyspepsia without Ulcer JON A. JOHNSON, M . D , ,
P H . D . a n d K A R L - E R ! K GIERCKSKY, M . D .
Department of Surgery, Institute of Clinical Medicine, Universityof Tromsr Tromsr Norway Fifty,two operations were performed on 44 patients with recurrent disease after vagotomy and drainage (38) or vagotomy without drainage (6). The initial vagotomy was done for duodenal ulcer (23), gastric ulcer (17), and acid dyspepsia without ulcer (4). The reoperations were 31 revagotomies, 11 Biilroth II gastric resections, 2 gastrojejunostomies, and later 4 gastric resections for another recurrence, 2 gastrojejunostomies for retention, and 2 operations for dumping. After an observation period of 1 to 6 year s (mean 2.5 years), the results were good in 22 patients, satisfactory in 20 and unsatisfactory in 2 patients. Of 42 patients with recurrent disease, 41 showed a significant increase of acid output during insulin stimulation before operative treatment of the recurrence. Of 31 revagotomized patients, 26 were insulin-test negative without later signs of recurrence. Five patients remained insulintest positive, and 4 of these required gastric resection for another recurrence. This series demonstrates the therapeutic significance of complete vagotomy, and emphasizes the value of the insulin test for evaluation of the completeness of the vagotomy.
For many years vagotomy has been the most widely used surgical procedure for treatment of duodena/ ulcer in the Western world. Vagotomy is also used to treat gastric ulcer in some centers. Its most serious disadvantage is a relatively high rate of recurrent disease. In spite of this, detailed reports of series of such recurrences have been infrequent [1-4].
Reprint requests: Jon A. Johnson, M.D., Departmen t of Surgery, Institute of Clinical Medicine, University of Tromsr 9000 Tromsr Norway.
It is commonly believed that the main cause of recurrent disease following vagotomy is incomplete vagotomy, which in most cases can be identified by the demonstration of increased acid output in response to insulin stimulation. However, in recent years a number of reports have been published which give the impression that recurrence of disease has little or no relationship to whether the insulin test is negative or positive [3, 5]. These reports have undermined confidence in the insulin test and conflict with our experience. In the present paper clinical data are presented that demonstrate the significance o f complete vagotomy to avoid recurrence of peptic ulcer and the role of the insulin test for evaluation of the completeness of the vagotomy. Materials and Methods
From 1967 to 1975, 426 patients underwent vagotomy, 334 electively and 92 as an emergency procedure. The incidence of duodenal ulcer, gastric ulcer, and acid dyspepsia without ulcer in this group, and the types of vagotomy performed are shown in Table i. Selective gastric vagotomy (SGV) involved a radical stripping of all extramuscular tissue, including the serosal layer, around the esophagogastric junction. Recently, the operation of proximal gastric vagotomy without drainage has been used for duodenal ulcer. The types of drainage procedure are presented in Table 2. All gastric ulcers were excised. Studies of gastric acid secretion were performed in all patients pre- and postoperatively and included measurements of basal secretion for 1 hour and hista-
494
World J. Surg. Vol. 1, No. 4, July, 1977
Table 1. Types of disease, types of vagotomy, and incidence of recurrent disease in 426 patients treated from 1967 to 1975.
Type of disease
No. of patients
Recurrences No. %
Duodenal ulcer 231 Gastric ulcer 165 Acid dyspepsia without ulcer 30 Total
426
23 17
10.0 10.3
4
13.5
44
10.3
Type ofvagotomy
No. of patients
Recurrences No. %
Truncal (TV + P) Selectivegastric (SGV + P) Proximal gastric (PGV)
33 343 50
3 35 6
9.1 10.2 12.0
426
44
10.3
mine-stimulated secretion for 2 hours. In addition, after vagotomy insulin-stimulated secretion was measured for 2 hours. The gastric contents were aspirated manually every t5 minutes,and the hydrochloric acid content recorded quantitatively as mEq/hr. The insulin test was considered positive when the acid output increased at least 2 mEq during the first or second hour of the test. However, in cases with a low histamine-stimulated acid output preoperatively, a somewhat smaller acid response was considered an expression of incomplete vagotomy. Approximately 25% of the insulin tests in the total series were positive by the criterion of a 2 m E q / h r increase in acid secretion. The diagnosis of recurrent disease was based on one or more of lhe following criteria: (a) recurrent symptoms of dyspepsia, (b) demonstration of an ulcer by diagnostic tests, (c) significant gastric retention, and (d) gastroduodenal bleeding. When recurrence was suspected, the insulin test was performed and often repeated several times. Recurrent disease developed m 44 patients, 35 men and 9 women, 22 to 73 years of age. The initial operation was done for duodenal ulcer in 23 Patients, gastric ulcer in 17, and acid dyspepsia without ulcer in 4. The types of recurrent disease after vagotomy are listed in Table 3. The diagnosis of recurrence was made in 16 patients without demonstration of an ulcer. Nine patients had gastric retention as a manifestation of recurrence and 5 h a d gastroduodenal bleeding that required at least 5 units of blood transfusion, and in one case led to an emergency operation. The time from the primary operation to the treatment of recurrent disease ranged from 2 to 84 months with a mean of 24 months. Fifteen patients
Table 2. Types of drainage procedures used in 426 patients. Pyloroplasty--Finney Pyloroplasty--Heineke Mikulicz Gastrojejunostomy None (PGV)
35 321 20 50 426
required reoperation during the first year after the initial operation. Recurrent disease was treated mainly by revag0tomy. When this was considered technically too difficult, Billroth II resection of 60 to 70% of the stomach was done. The types of operative treatment for recurrent disease are presented in Table 4. Two patients with retention and an acid response to insulin of 2 and 3.2 mEq/hr, respectively, were treated with gastrojejunostomy. Eight patients required additional operations after the second procedure. All in all, 44 patients underwent 52 operative procedures, 48 for recurrence, 2 for retention, and 2 for dumping. Follow-up evaluations were performed by questionnaires at the time of outpatient visits, subsequent hospital admissions, or by mail. The follow-up period after the last operation ranged from l t o 6 years with a mean of 2.6 years. Results
Insulin Tests
The insulin test was positive in 38 patients with a mean resPonse of 14.7 m E q / h r for patients with duodenal ulcer recurrence and 8.1 m E q / h r for patients with gastric ulcer recurrence, Three patients with recurrent disease (2 with gastric ulcer and ! with acid dyspepsia without ulcer) showed insulin,test responses of 1.3, 1.0 and 1.3 mEq/hr, respectively, which were interpreted as probable expressions of incomplete vagotomy. One patient With recurrence of duodenal ulcer showed no response to 3 consecutive insulin stimulation tests in spite of a response of 28.5 m E q / h r to maximal histamine stimulation, a discrepancy we are unable to explain. In 2 patients with recurrence of gastric ulcer, 1 with profuse bleeding, the test was not performed (Table 5). Twenty-six of 31 revagotomized patients were insulin-test negative (84%) and did not develop another recurrence. Five patients remained insulin-test positive after revagotomy with responses of 2.0, 7.3, 12.5, 16.4 and 23.8 mEq/hr, respectively. Four of them underwent later gastric resections for another recurrence of disease.
J.A. Johnson and K.-E. Giercksky: Surgery for Postvagotomy Recurrent Disease
495
Table 3. Type of recurrent disease after vagotomy in 44 patients.
Type of Recurrence Initial disease Duodenal ulcer Gastric ulcer Acid dyspepsia
Duodenal ulcer
Gastric ulcer
Acid dyspepsia
Gastric retention
Gastroduodenal bleeding
9 2 0
5 12 0
9 3 4
4 5 0
2 3 0
11
17
16
9
5
Table 4. Operative treatment of recurrent disease after
vagotorny in 44 patients: No. of operations
Operation
Revagotomy alone 15 Revagotomy combined with: Excision of gastric ulcer 7 Gastrojejunostomy (4) or pyloroplasty (1) 5 Biopsy or excision of gastric ulcer and gastrojejunostomy 2 Excision of pyloric ulcer, revision of pyloroplasty 1 Revision of pyloroplasty 1 Billroth II gastric resection 11 Gastrojejunostomy 2 Later operations: Billroth II gastric resection for another recurrence 4 Gastrojejunostomy for retention 2 Operation for dumping 2 52 Table 5. Insulin tests in 44 patients with recurrent disease.
Positive Response below 2 mEq/hr Nonresponse Test not performed
38 3 l 2
Complications One revagotomized patient developed a fistula from the stomach to the abdominal wound which healed during feeding through a tube jejunostomy. Splenectomy in connection with revagotomy was followed in 3 patients by pancreatic fistula, which led to another operation in 1 patient. One patient had to be reoperated upon due to anastomotic leak after gastric resection. All patients survived the complications. Other complications were of minor importance.
Clinical Evaluation The results were good in 22 patients with cure or marked improvement of the dyspepsia and only moderate side effects. The results were satisfactory in 20 patients with decreased dyspepsia and moderate side effects, and unsatisfactory in 2 patients due to postoperative cardiac insufficiency with moderate but troublesome esophagitis in one and dumping complaints in the other. Discussion
Of 42 patients with recurrence of peptic disease after vagotomy, 41 showed significantly increased acid output in response to insulin stimulation. Among 31 revagotomized patients, 4 of 5 with a persistently positive insulin test developed another recurrence, while no recurrence occurred in 26 patients with a negative insulin test. These data are in good agreement with those of Fawcett et al. [1] who reported the results of insuli n stimulation and revagotomy in 74 patients with ulcer recurrence. Our experience and that of Fawcett et al. represent a convincing demonstration of the therapeutic effect of complete vagotomy in the treatment of peptic ulcer, and confirm the validity of the acid response to insulin stimulation as an expression of incomplete vagotomy. T h e lack of correspondence between the appearance of recurrent disease and positive insulin tests in other series [3, 5] is not easy to explain. Insulin tests performe d many years after the initial operation may possibly explain some of the discrepancies. It is reported [6, 7] that patients with negative postoperative insulin tests regain 8-10% of the preoperative acid response to insulin stimulation during a period of 5 years after Vagotomy. The cause of this is not known. The small return of acid response does not seem to carry much risk of recurrence [8]. It indicates that insulin tests performed late after vagotomy should be evaluated in the light of secretory data from before
496 and soon after operation. Perhaps then, differences in opinion on the validity of the insulin test would be less prominent. The revagotomy operations were followed by one instance of external gastric fistula, one case of clinically significant cardiac insufficiency, 3 cases of external pancreatic fistula, the need for 2 drainage operations for gastric retention, and 4 difficult gastric resections for another recurrence of disease. N o recurrent disease appeared after Billroth II gastric resection, but reoperation was required in 1 patient for anastomotic leak and in 2 for dumping. Fortunately, there were no operative deaths in this study; however. a mortality rate of 6% occurred after gastric resection in a corresponding series [2]. Operative treatment Of recurrence after vagotomy undoubtedly carries a considerable risk for a benign disease such as peptic ulcer. Since the operative risk of primary surgical treatment is far less. there are strong i'easons for making the first operation a definitive surgical treatment. In our opinion, the recurrence rate of 10% following initial surgical treatment in our series is too high. We are convinced that the recurrences were caused by incomplete vagotomy which are reflected in the 25% rate of positive insulin tests. In order to improve our results we have established the policy that all elective vagotomies are performed by surgeons attached to the gastroenterological unit. that a postoperative insulin test is mandatory, and that the results of the test be presented to the operating surgeon. As a result of this policy, the rate of positive insulin tests has recently fallen to 10% and. therefore, we anticipate a significant reduction in the incidence of recurrent disease in ~he future. A recurrence rate around 5% would be acceptable for present-day peptic ulcer surgery. R6sume Quarante-quatre malades vagotomis6s avec (38) ou sans (6) drainage, p o u r ulc6re duod6nal (23 cas), ulc6re gastrique (17 cas) ou dyspepsie acide sans ulc6re (4 cas I, ont dfi subir 52 r6interventions pour r6cidive de la maladie. Ces r6interventions ont comport6 31 vagotomies, 11 gastrectomies de type Billroth II. 2
World J. Surg. Vo !. 1, No. 4, July, 1977 gastroent6rostomies et, u!t6rieurement, 4 gastrectomies pour une nouve!le r6cidive, 2 gastroent6rostomies pour stase gastrique et 2 op6rations pour dumping. Apr6s 1-6 ans (moyenne 2.5 ans), les r6sultats sont bons dans 22 cas, satisfaisants dans 20 et mauvais dans 2. Sur 42 malades ayant une r6cidive, 41 avaient une r6ponse s6cr6toire ~. l'insuline avant ia r6intervention. Sur 31 malades ayant subi une deuxi6me vagotomie, le test /t l'insuline postop6ratoire est n6gatif dans 26 cas, qui sont sans symptomes de r6cidive ulc6reuse. Mais, darts 5 cas, le test est rest6 positif et 4 d'entre eux ont dfi 6tre gastrectomis6s pour un nouvet ulc6re. Ce travail montre que la vagotomie doit 6tre compl6te pour 6tre efficace et souligne la valeur du test a" 1' insuline.
References 1. Fawcett, A.N., Johnston, D., Duthie, H.L.: Revagotomy for recurrent ulcer after vagotomy and drainage for duodenal ulcer. Br. J. Surg. 62:111, 1969 2. Stuart, M., Stanley, O.H.: Recurrent peptic ulcer following primary operations with vagotomy for duodenal ulcer. Arch. Surg. 103:12~, 1976 3. Kronborg, O.: A follow-up of patients operated upon for recurrence after vagot0my and drainage for duodenal ulcer. Scand. J. Gastroenterol. 8:123, 1972 4. Lindenauer, S.M, Dent, T.L.: Management of the recurrent ulcer. Arch. Surg. 110:531, 1975 5. Kronborg, O., Madsen, P.: Relationship between gastric acid secretion and recurrent duodenal ulcer after selective vag0tOmy and pyloroplasty in men. Scand. J. Gastroenterol. 11:465, 1976 6. Johnston, D., Wilkinson, A.R., Goligher, J.C., Kragelund E., Amdrup, E.: Serial studies of gastric secretion in patients after highly selective (parietal cell) vagotomy without a drainage procedure for duodenal ulcer. II. The insulin test after highly selective vagotomy. Gastroentero!ogy 64:12, 1973 7. Lyndon, P.J., Geenall, M.J., Smith, R.B., Goligher, J.C., Johnston D.: Serial insulin test over a five-year period after highly se!ective vagotomy for duodenal ulcer. Gastroenterology 69:1188, 1975 8. Amdrup, E., Jensen, H.E., Johnston, D., Walker, B.E., Goligher, J.C.; Clinical results of parietal cell vagotomy (highly selective vagotomy) two to four years after Operation. Ann. Surg. 180:279, 1974
---)~ ~~ p v B
9 1977 by the Soci6t~ Internationale de Chirurgie
ORIGINAL SCIENTIFIC REPORTS Operative Treatment of Recurrence after Vagotomy and Drainage for Duodenal Ulcer, Gastric Ulcer, and Acid Dyspepsia without Ulcer JON A. JOHNSON, M . D , ,
P H . D . a n d K A R L - E R ! K GIERCKSKY, M . D .
Department of Surgery, Institute of Clinical Medicine, Universityof Tromsr Tromsr Norway Fifty,two operations were performed on 44 patients with recurrent disease after vagotomy and drainage (38) or vagotomy without drainage (6). The initial vagotomy was done for duodenal ulcer (23), gastric ulcer (17), and acid dyspepsia without ulcer (4). The reoperations were 31 revagotomies, 11 Biilroth II gastric resections, 2 gastrojejunostomies, and later 4 gastric resections for another recurrence, 2 gastrojejunostomies for retention, and 2 operations for dumping. After an observation period of 1 to 6 year s (mean 2.5 years), the results were good in 22 patients, satisfactory in 20 and unsatisfactory in 2 patients. Of 42 patients with recurrent disease, 41 showed a significant increase of acid output during insulin stimulation before operative treatment of the recurrence. Of 31 revagotomized patients, 26 were insulin-test negative without later signs of recurrence. Five patients remained insulintest positive, and 4 of these required gastric resection for another recurrence. This series demonstrates the therapeutic significance of complete vagotomy, and emphasizes the value of the insulin test for evaluation of the completeness of the vagotomy.
For many years vagotomy has been the most widely used surgical procedure for treatment of duodena/ ulcer in the Western world. Vagotomy is also used to treat gastric ulcer in some centers. Its most serious disadvantage is a relatively high rate of recurrent disease. In spite of this, detailed reports of series of such recurrences have been infrequent [1-4].
Reprint requests: Jon A. Johnson, M.D., Departmen t of Surgery, Institute of Clinical Medicine, University of Tromsr 9000 Tromsr Norway.
It is commonly believed that the main cause of recurrent disease following vagotomy is incomplete vagotomy, which in most cases can be identified by the demonstration of increased acid output in response to insulin stimulation. However, in recent years a number of reports have been published which give the impression that recurrence of disease has little or no relationship to whether the insulin test is negative or positive [3, 5]. These reports have undermined confidence in the insulin test and conflict with our experience. In the present paper clinical data are presented that demonstrate the significance o f complete vagotomy to avoid recurrence of peptic ulcer and the role of the insulin test for evaluation of the completeness of the vagotomy. Materials and Methods
From 1967 to 1975, 426 patients underwent vagotomy, 334 electively and 92 as an emergency procedure. The incidence of duodenal ulcer, gastric ulcer, and acid dyspepsia without ulcer in this group, and the types of vagotomy performed are shown in Table i. Selective gastric vagotomy (SGV) involved a radical stripping of all extramuscular tissue, including the serosal layer, around the esophagogastric junction. Recently, the operation of proximal gastric vagotomy without drainage has been used for duodenal ulcer. The types of drainage procedure are presented in Table 2. All gastric ulcers were excised. Studies of gastric acid secretion were performed in all patients pre- and postoperatively and included measurements of basal secretion for 1 hour and hista-
494
World J. Surg. Vol. 1, No. 4, July, 1977
Table 1. Types of disease, types of vagotomy, and incidence of recurrent disease in 426 patients treated from 1967 to 1975.
Type of disease
No. of patients
Recurrences No. %
Duodenal ulcer 231 Gastric ulcer 165 Acid dyspepsia without ulcer 30 Total
426
23 17
10.0 10.3
4
13.5
44
10.3
Type ofvagotomy
No. of patients
Recurrences No. %
Truncal (TV + P) Selectivegastric (SGV + P) Proximal gastric (PGV)
33 343 50
3 35 6
9.1 10.2 12.0
426
44
10.3
mine-stimulated secretion for 2 hours. In addition, after vagotomy insulin-stimulated secretion was measured for 2 hours. The gastric contents were aspirated manually every t5 minutes,and the hydrochloric acid content recorded quantitatively as mEq/hr. The insulin test was considered positive when the acid output increased at least 2 mEq during the first or second hour of the test. However, in cases with a low histamine-stimulated acid output preoperatively, a somewhat smaller acid response was considered an expression of incomplete vagotomy. Approximately 25% of the insulin tests in the total series were positive by the criterion of a 2 m E q / h r increase in acid secretion. The diagnosis of recurrent disease was based on one or more of lhe following criteria: (a) recurrent symptoms of dyspepsia, (b) demonstration of an ulcer by diagnostic tests, (c) significant gastric retention, and (d) gastroduodenal bleeding. When recurrence was suspected, the insulin test was performed and often repeated several times. Recurrent disease developed m 44 patients, 35 men and 9 women, 22 to 73 years of age. The initial operation was done for duodenal ulcer in 23 Patients, gastric ulcer in 17, and acid dyspepsia without ulcer in 4. The types of recurrent disease after vagotomy are listed in Table 3. The diagnosis of recurrence was made in 16 patients without demonstration of an ulcer. Nine patients had gastric retention as a manifestation of recurrence and 5 h a d gastroduodenal bleeding that required at least 5 units of blood transfusion, and in one case led to an emergency operation. The time from the primary operation to the treatment of recurrent disease ranged from 2 to 84 months with a mean of 24 months. Fifteen patients
Table 2. Types of drainage procedures used in 426 patients. Pyloroplasty--Finney Pyloroplasty--Heineke Mikulicz Gastrojejunostomy None (PGV)
35 321 20 50 426
required reoperation during the first year after the initial operation. Recurrent disease was treated mainly by revag0tomy. When this was considered technically too difficult, Billroth II resection of 60 to 70% of the stomach was done. The types of operative treatment for recurrent disease are presented in Table 4. Two patients with retention and an acid response to insulin of 2 and 3.2 mEq/hr, respectively, were treated with gastrojejunostomy. Eight patients required additional operations after the second procedure. All in all, 44 patients underwent 52 operative procedures, 48 for recurrence, 2 for retention, and 2 for dumping. Follow-up evaluations were performed by questionnaires at the time of outpatient visits, subsequent hospital admissions, or by mail. The follow-up period after the last operation ranged from l t o 6 years with a mean of 2.6 years. Results
Insulin Tests
The insulin test was positive in 38 patients with a mean resPonse of 14.7 m E q / h r for patients with duodenal ulcer recurrence and 8.1 m E q / h r for patients with gastric ulcer recurrence, Three patients with recurrent disease (2 with gastric ulcer and ! with acid dyspepsia without ulcer) showed insulin,test responses of 1.3, 1.0 and 1.3 mEq/hr, respectively, which were interpreted as probable expressions of incomplete vagotomy. One patient With recurrence of duodenal ulcer showed no response to 3 consecutive insulin stimulation tests in spite of a response of 28.5 m E q / h r to maximal histamine stimulation, a discrepancy we are unable to explain. In 2 patients with recurrence of gastric ulcer, 1 with profuse bleeding, the test was not performed (Table 5). Twenty-six of 31 revagotomized patients were insulin-test negative (84%) and did not develop another recurrence. Five patients remained insulin-test positive after revagotomy with responses of 2.0, 7.3, 12.5, 16.4 and 23.8 mEq/hr, respectively. Four of them underwent later gastric resections for another recurrence of disease.
J.A. Johnson and K.-E. Giercksky: Surgery for Postvagotomy Recurrent Disease
495
Table 3. Type of recurrent disease after vagotomy in 44 patients.
Type of Recurrence Initial disease Duodenal ulcer Gastric ulcer Acid dyspepsia
Duodenal ulcer
Gastric ulcer
Acid dyspepsia
Gastric retention
Gastroduodenal bleeding
9 2 0
5 12 0
9 3 4
4 5 0
2 3 0
11
17
16
9
5
Table 4. Operative treatment of recurrent disease after
vagotorny in 44 patients: No. of operations
Operation
Revagotomy alone 15 Revagotomy combined with: Excision of gastric ulcer 7 Gastrojejunostomy (4) or pyloroplasty (1) 5 Biopsy or excision of gastric ulcer and gastrojejunostomy 2 Excision of pyloric ulcer, revision of pyloroplasty 1 Revision of pyloroplasty 1 Billroth II gastric resection 11 Gastrojejunostomy 2 Later operations: Billroth II gastric resection for another recurrence 4 Gastrojejunostomy for retention 2 Operation for dumping 2 52 Table 5. Insulin tests in 44 patients with recurrent disease.
Positive Response below 2 mEq/hr Nonresponse Test not performed
38 3 l 2
Complications One revagotomized patient developed a fistula from the stomach to the abdominal wound which healed during feeding through a tube jejunostomy. Splenectomy in connection with revagotomy was followed in 3 patients by pancreatic fistula, which led to another operation in 1 patient. One patient had to be reoperated upon due to anastomotic leak after gastric resection. All patients survived the complications. Other complications were of minor importance.
Clinical Evaluation The results were good in 22 patients with cure or marked improvement of the dyspepsia and only moderate side effects. The results were satisfactory in 20 patients with decreased dyspepsia and moderate side effects, and unsatisfactory in 2 patients due to postoperative cardiac insufficiency with moderate but troublesome esophagitis in one and dumping complaints in the other. Discussion
Of 42 patients with recurrence of peptic disease after vagotomy, 41 showed significantly increased acid output in response to insulin stimulation. Among 31 revagotomized patients, 4 of 5 with a persistently positive insulin test developed another recurrence, while no recurrence occurred in 26 patients with a negative insulin test. These data are in good agreement with those of Fawcett et al. [1] who reported the results of insuli n stimulation and revagotomy in 74 patients with ulcer recurrence. Our experience and that of Fawcett et al. represent a convincing demonstration of the therapeutic effect of complete vagotomy in the treatment of peptic ulcer, and confirm the validity of the acid response to insulin stimulation as an expression of incomplete vagotomy. T h e lack of correspondence between the appearance of recurrent disease and positive insulin tests in other series [3, 5] is not easy to explain. Insulin tests performe d many years after the initial operation may possibly explain some of the discrepancies. It is reported [6, 7] that patients with negative postoperative insulin tests regain 8-10% of the preoperative acid response to insulin stimulation during a period of 5 years after Vagotomy. The cause of this is not known. The small return of acid response does not seem to carry much risk of recurrence [8]. It indicates that insulin tests performed late after vagotomy should be evaluated in the light of secretory data from before
496 and soon after operation. Perhaps then, differences in opinion on the validity of the insulin test would be less prominent. The revagotomy operations were followed by one instance of external gastric fistula, one case of clinically significant cardiac insufficiency, 3 cases of external pancreatic fistula, the need for 2 drainage operations for gastric retention, and 4 difficult gastric resections for another recurrence of disease. N o recurrent disease appeared after Billroth II gastric resection, but reoperation was required in 1 patient for anastomotic leak and in 2 for dumping. Fortunately, there were no operative deaths in this study; however. a mortality rate of 6% occurred after gastric resection in a corresponding series [2]. Operative treatment Of recurrence after vagotomy undoubtedly carries a considerable risk for a benign disease such as peptic ulcer. Since the operative risk of primary surgical treatment is far less. there are strong i'easons for making the first operation a definitive surgical treatment. In our opinion, the recurrence rate of 10% following initial surgical treatment in our series is too high. We are convinced that the recurrences were caused by incomplete vagotomy which are reflected in the 25% rate of positive insulin tests. In order to improve our results we have established the policy that all elective vagotomies are performed by surgeons attached to the gastroenterological unit. that a postoperative insulin test is mandatory, and that the results of the test be presented to the operating surgeon. As a result of this policy, the rate of positive insulin tests has recently fallen to 10% and. therefore, we anticipate a significant reduction in the incidence of recurrent disease in ~he future. A recurrence rate around 5% would be acceptable for present-day peptic ulcer surgery. R6sume Quarante-quatre malades vagotomis6s avec (38) ou sans (6) drainage, p o u r ulc6re duod6nal (23 cas), ulc6re gastrique (17 cas) ou dyspepsie acide sans ulc6re (4 cas I, ont dfi subir 52 r6interventions pour r6cidive de la maladie. Ces r6interventions ont comport6 31 vagotomies, 11 gastrectomies de type Billroth II. 2
World J. Surg. Vo !. 1, No. 4, July, 1977 gastroent6rostomies et, u!t6rieurement, 4 gastrectomies pour une nouve!le r6cidive, 2 gastroent6rostomies pour stase gastrique et 2 op6rations pour dumping. Apr6s 1-6 ans (moyenne 2.5 ans), les r6sultats sont bons dans 22 cas, satisfaisants dans 20 et mauvais dans 2. Sur 42 malades ayant une r6cidive, 41 avaient une r6ponse s6cr6toire ~. l'insuline avant ia r6intervention. Sur 31 malades ayant subi une deuxi6me vagotomie, le test /t l'insuline postop6ratoire est n6gatif dans 26 cas, qui sont sans symptomes de r6cidive ulc6reuse. Mais, darts 5 cas, le test est rest6 positif et 4 d'entre eux ont dfi 6tre gastrectomis6s pour un nouvet ulc6re. Ce travail montre que la vagotomie doit 6tre compl6te pour 6tre efficace et souligne la valeur du test a" 1' insuline.
References 1. Fawcett, A.N., Johnston, D., Duthie, H.L.: Revagotomy for recurrent ulcer after vagotomy and drainage for duodenal ulcer. Br. J. Surg. 62:111, 1969 2. Stuart, M., Stanley, O.H.: Recurrent peptic ulcer following primary operations with vagotomy for duodenal ulcer. Arch. Surg. 103:12~, 1976 3. Kronborg, O.: A follow-up of patients operated upon for recurrence after vagot0my and drainage for duodenal ulcer. Scand. J. Gastroenterol. 8:123, 1972 4. Lindenauer, S.M, Dent, T.L.: Management of the recurrent ulcer. Arch. Surg. 110:531, 1975 5. Kronborg, O., Madsen, P.: Relationship between gastric acid secretion and recurrent duodenal ulcer after selective vag0tOmy and pyloroplasty in men. Scand. J. Gastroenterol. 11:465, 1976 6. Johnston, D., Wilkinson, A.R., Goligher, J.C., Kragelund E., Amdrup, E.: Serial studies of gastric secretion in patients after highly selective (parietal cell) vagotomy without a drainage procedure for duodenal ulcer. II. The insulin test after highly selective vagotomy. Gastroentero!ogy 64:12, 1973 7. Lyndon, P.J., Geenall, M.J., Smith, R.B., Goligher, J.C., Johnston D.: Serial insulin test over a five-year period after highly se!ective vagotomy for duodenal ulcer. Gastroenterology 69:1188, 1975 8. Amdrup, E., Jensen, H.E., Johnston, D., Walker, B.E., Goligher, J.C.; Clinical results of parietal cell vagotomy (highly selective vagotomy) two to four years after Operation. Ann. Surg. 180:279, 1974
