ANNALS Vol. 183
OF SURGERY
June 1976
No.
6
Vagotomy and Drainage Procedure for Duodenal Ulcer: The Results of Seventeen Years' Experience J. PATRICK O'LEARY, M.D., E. R. WOODWARD, M.D., J. 1. HOLLENBECK, M.D., L. R. DRAGSTEDT, PH.D., M.D.*
During the 10 years prior to January, 1968, 455 duodenal From the Department of Surgery, College of Medicine, ulcer patients were operated upon at the University of Florida University of Florida, Gainesville, affiliated hospitals. The early results were reported in 1969. The Florida, 32610 present study is a followup of the same patients now 7 to 17 years after vagotomy and drainage. Twenty-four per cent were lost to followup. The ulcer recurrence rate was 5.8 per cent. All the recurrent ulcers that were not gastric in location (4.9%) occurred within 5 years after the original operative procedure cedure on 455 patients who have now been followed with a mean of 2.6 years. The gastric ulcers (0.9%) occurred from 7 to 17 years. at a much later date with a mean of 6 years. It is concluded that vagotomy and gastric drainage is a satisfactory modality of Clinical Material therapy for duodenal ulcer. It can be accomplished with an acceptable morbidity and mortality and the long-term recurrence The patients who comprise the population for this rate is low. If recurrences due to incomplete vagotomy do not occur within 5 years, they are unlikely to recur. study were operated upon between October of 1958 and
T HE RESULTS of the accepted modalities of surgical therapy for duodenal ulcer have been generally good. Only small differences exist between the various procedures; however, because of the large number of patients treated each year these differences become significant. Many authors have alluded to the higher incidence of recurrence after vagotomy and a drainage procedure as being its major drawback.147 This paper deals with the results of vagotomy and drainage proPresented at the Annual Meeting of the Southern Surgical Association, December 8-10, 1975, The Homestead, Hot Springs, Virginia. This work has been supported by National Institutes of Health grant number AM-04178. Reprint requests: J. P. O'Leary, M.D., Department of Surgery, Box J-286, College of Medicine, University of Florida, Gainesville, Florida 32610. *
Deceased.
January of 1968. These patients were first reported in the Annals of Surgery in 1969.3 Followup has now been extended to a minimum of 7 years and a maximum of 17 years. In the original study there were 455 patients, seven of whom were lost to followup. In the present study 348 patients were evaluated. Of these, 85 are now dead. Only one of the deaths was related to the patient's ulcer disease and occurred at the time of a subsequent gastric resection. One hundred and seven of the 455 were lost to followup leaving 76% of the original patients accounted for in the study. The demographic data for this group were reported in the previous evaluation. Significant parameters reveal that there was a preponderance of Caucasian versus Negro patients (382/72), males versus females (415/40), skilled and unskilled versus professional and executive individuals (280/67). The age range in the group was from 8 years to 83 years with an average age of 49 years; 45% were 50 years old or older. The population of the present group reflects the increasing age
613
614
O'LEARY AND OTHERS
TABLE 1. Indication for Operation
Elective 401/455 (88%)Patients 1. Intractability 2. Inability to adhere to medical treatment 3. Recurrent hemorrhage previous perforation symptoms of hiatus hernia 4. Obstruction Emergency 54/455 (12%)Patients 1. Hemorrhage 2. Perforation
No. Patients
Per cent
265/401 22/401
66 5
68/401 46/401
17 12
46/54 8/54
85 15
of the group as a whole, but was consistent with the age distribution of the original group. Two hundred and seventy-three (60%) had suffered at least one hemorrhage prior to their surgery and 79 (17%) had a history of previous perforation. Forty-five patients were operated upon as emergencies and 409 (90%) had undergone medical management. Forty per cent of all the patients had coexistent diseases at the time of range
surgery.
The indications for surgery are listed in Table 1. The were done for intractability (66%). The operative mortality was 1% in 401 elective procedures and 2% in 44 emergency procedures. In 416 (91%) a vagotomy and pyloroplasty was the procedure of choice while in 39 (9%) the drainage procedure was a gastroenterostomy. A tube gastrostomy was employed in 94% of the cases (Table 2).
great majority
Followup
Followup was accomplished by direct evaluation in the clinic, home visits, written responses to questionnaires or telephone conversations. In instances where questions arose, the patient's family physician was contacted directly. All patients in this series were followed a minimum of 7 years and some as long as 17 years postoperatively. The average followup was 10 years. Recurrences A standard definition of recurrent ulcer disease was used as described by Weinberg1" i.e.: 1) persistence of ulceration following operation; 2) ulceration in a new site; 3) recurrence after an interval of apparent complete healing; 4) any suspected recurrence of ulceration unless proven not to exist. These are the same criteria used in
the earlier study. In the 257 patients who were evaluated, 6 had developed recurrent duodenal or marginal ulcer and 4 had developed a gastric ulcer. In the group studied, this is an incidence of recurrence of 10 out of 257 or 4%.
Ann. Surg. * June 1976
When the 10 recurrences in this group are added to the 16 recurrences found in the original study, the overall incidence of recurrence is 5.8% (Table 3). Of the 6 patients who developed a duodenal recurrence, 4 had had a vagotomy and pyloroplasty with gastrostomy while two had had a vagotomy and gastroenterostomy. The latent period from the time of surgery to recurrence ranged from one year to 5 years with a mean of 2.6 years. Five of these patients required reoperation. One of the patients with a gastroenterostomy bled 11/2 years after his original operation. He was demonstrated to have another duodenal ulcer; his small gastroenterostomy was taken down and a Finney pyloroplasty fashioned. The other patient with a gastroenterostomy developed a marginal ulcer two years after his original surgery. He was operated upon and an antrectomy with gastroduodenostomy was performed. Both patients are now free of disease. Three of the remaining four patients with recurrent duodenal ulcers have undergone gastric resection. One of these had recurrent hemorrhage while the others had recurrent symptoms. The fourth patient has bled, but has not required surgical intervention. All of these patients had experienced recurrent abdominal pain. In the group of 4 patients who developed a gastric ulcer, one had a vagotomy with gastroenterostomy while the remaining three had a vagotomy and pyloroplasty. The latent period varied from 5 to 8 years with a mean of 6 years. Two of the ulcers were discovered at autopsy. One was described as an acute gastric erosion and occurred in a patient who survived two days after a myocardial infarction. The second was a chronic ulcer found in an elderly man who died of pneumonia. The third was treated with a gastric resection and gastroduodenostomy while the fourth was treated nonoperatively. In this group, two had originally been TABLE 2. Operative Procedure
Primary Vagotomy and pyloroplasty 1. Weinberg 2. Finney Vagotomy and Gastroenterostomy Total Gastrostomy Incidental (120 or 26% patients) Hiatal herniorrhaphy
Cholecystectomy Appendectomy Splenectomy Other
No. Patients
Per cent
416/455 407/416 9/416 39
91
455 428
100 94
48 21 16 6 29
11 5 3 1 6
9
Vol. 183 . NO. 6
VAGOTOMY FOR DUODENAL ULCER TABLE 3. Recurrent Ulcer
3V4 Years
10 Years
Per cent
Suspected
13/443 3/443
23/443 3/443
5.2 .6
TOTAL
16/443
26/443
5.8
Proved
57%
Highly pleased Satisfied Not satisfied Highly dissatisfied Feel better Feel same Feel worse
No. Patients/Average Followup
Overall
615 TABLE 4. Results
30%0 7% 6% 87% 7% 6%
grees was a problem in 40% of patients. Of the 37 asfor pain one intractability, for operated patients who were able to compare it to their prerepeated of one because and with hemorrhage, sociated operative pain, 62% felt that it was the same while 8% this in individuals the of Two bouts of obstruction. felt that it was less severe and 30% felt that it was procedures. gastric group had had previous more severe. Vomiting was not a problem in 86% of the patients. Of Dumping the 14% in whom it was a problem, 3% felt the problem was mild, 4% felt the problem was moderate, and Although there was a significant incidence of patients 7% felt that the problem was severe. Bloating was present complaining of abdominal distress, true "dumping" was in 55% of the patients. It was classified as mild in 14%, relatively infrequent. The dumping syndrome was divided moderate in 24% and severe in 17%. into two major classifications. The first group included Forty-two or 16% of the patients had experienced those who demonstrated the effects of volume shifts after bleeding from the G.I. tract. Seven of these 42 patients the ingestion of a food; this was termed early had apparently rebled from ulcer disease and were listed dumping. The second group included those who de- as recurrences. The rest of the patients bled from other veloped symptoms of hypoglycemia two to 4 hours after parts of the G.I. tract. The most common site of origin eating; this was termed late dumping. was hemorrhoids. All patients who responded positively Eight patients demonstrated early dumping while two to this item were contacted directly or evaluated by their exhibited late dumping. One patient demonstrated some family physician. symptoms of both. The majority of patients conThe majority of the patients, 82%, stated that they felt trolled their symptoms by regulation of their diet. None better while 12% felt that they were the same and 6% felt has required surgical intervention to alleviate these that they were worse. Six of this latter group of 15 exsymptoms. hibited a form of the dumping syndrome.
upon
Diarrhea Diarrhea was present in 16% of the series. The bulk of the patients who responded felt that it was mild, but 5% felt that it was a rather severe problem. Two of the patients had their lives moderated by the presence of this annoying symptom. It was interesting to note that three patients stated the ingestion of antacids diminished the frequency of their diarrhea. Others complained of frequent stools, but true diarrhea was not present.
Subjective Evaluation Patients were asked to answer a standard questionnaire in regard to a variety of different symptoms that could be associated with their operations. Eighty-seven per cent of patients were either highly pleased or satisfied with the results of their surgery while 7% were not satisfied and 5% were highly dissatisfied (Table 4). Despite this apparent generally positive feeling toward the procedure, 53% of patients complained that they were still having some stomach problems (Table 5). Pain of varying de-
Discussion
Morbidity and mortality from vagotomy and pyloroplasty and vagotomy with limited gastric resection have been extensively reported.1.3'4'7-10 In the well-trained hands of the investigators reporting these series the differences in mortality are small, but probably real. In many series mortality after a gastric resection, regardless how small, is 1½2 to 3 times that after a vagotomy and pyloroplasty.6.9 10 These data are gathered from centers where there is great interest in the care and treatment of duodenal ulcer. Although in some of these centers TABLE 5. Subjective Evaluations
Symptoms
None
Mild
7% 60% 3% 86% Vomiting 8% 84% Diarrhea 14% 45% Bloating Yes 53% Stomach Problems Pain
Moderate
21% 4% 3% 24% No 47%
Severe
12% 7% 5%
17%o
Ann. Surg. * June 1976 O'LEARY A,NID OTHERS 616 much of the surgery is done by housestaff, the pro- will steadily increase. This has not been the finding cedures are carefully supervised and experienced in this study. surgical judgment is exercised. When a difficult duoThe recurrence rate of peptic ulcer disease after a denum is encountered, the experienced gastrointestinal vagotomy and drainage procedure is 5.8%. Although surgeon assesses the situation and chooses an alternative the followup is only 76%, comparisons between the to gastric resection. Certainly not all duodenums lend Negro/Caucasion distribution ratio and the shape of the themselves to gastric resection, regardless of how small age distribution curve between the present patient poputhe resection may be. The potential problem resides lation and the original series suggests that a representaat the line of the anastomosis or closure, not during the tive sample has been obtained. actual resection. The reason that the skilled surgeon's All of the recurrences of duodenal ulcer occurred mortality with gastric resection approaches that of a within the first 5 years after surgery with an average vagotomy and drainage procedure is that he avoids po- lapse time of 2.6 years. When a patient developed a tentially lethal problems by selecting out the high risk gastric recurrence, it appeared between 5 and 8 years patient in the operating room. The surgeon who in- postoperatively with an average lapse time of 6 years. frequently faces these problems may not be as adept in All of the patients who developed recurrences that making these decisions. were not gastric ulcers developed them less than 5 years Morbidity is lower after a vagotomy and drainage pro- after their operation. Since all of the patients have now cedure than after a vagotomy and limited gastric re- been followed between 7 and 17 years with the section. Suture line disruption is less likely after a majority being followed more than 10 years, we believe pyloroplasty than after an antrectomy. Likewise, pan- that the vast majority of recurrences after incomplete creatic injury and subhepatic abscess are less likely vagotomy and pyloroplasty will occur within the first 5 after the former than after the latter. If the recon- years. Late recurrences in the form of gastric ulcer are struction after a gastrectomy is a gastrojejunostomy, then less common and have a latent period over 5 years. It the patient is at risk for various postgastrectomy syn- has been our experience that these are often associated dromes which are associated with the jejunal and duo- with unrelated acute illnesses or chronic debilitating denal limbs.5 These are obviated by a vagotomy and diseases. pyloroplasty. Bile gastritis has been reported after a References vagotomy and pyloroplasty, but it is certainly more W. M., Klein, D. and Griffen, W. 0. Jr.: The Role of common after a gastrectomy, especially if a Billroth 1. Bryant, Vagotomy in Duodenal Ulcer Surgery. Surgery, 61:864, 1964. II gastrojejunostomy has been constructed.2 2. Bushkin, F. L., DeFord, J. W., Wickbom, G. and Woodward, E. R.: A Clinical Evaluation of Postoperative Alkaline Reflux In this series approximately 95% of the procedures in Gastritis. 41:88, 1975. the Veterans Administration Hospital and approximately 3. Eisenberg, M.Am.M.,Surg., Woodward, E. R., Carson, T. J. and Drag75% of the procedures in the University Hospital stedt, L. R.: Vagotomy and Drainage Procedure for Duodenal Ulcer: The Results of 10 Years' Experience. Ann. Surg., 170: were performed by resident surgeons. Yet the mortality 317, and morbidity were acceptably low. We feel that the 4. Goligher,1969.J. C., Pulvertaft, C. N., Irvin, T. T., et al.: procedure is relatively simple and can be learned Five-to-Eight Year Results of Truncal Vagotomy and Pyloro-
quickly. As alluded to earlier, although there is only a small difference in the mortality, it is still significantly higher after a gastrectomy than after a vagotomy and drainage procedure. Although this difference is small, because of the large number of individuals operated upon each year the number of lives lost is significant. If a recurrence develops, the patient can be reoperated upon and a resection performed with no greater risk than other surgeons would accept for the primary procedure. The final question then seems to be the difference in the incidence of recurrence in patients after these procedures. It has been postulated that as large series of patients who have had vagotomy and a drainage procedure are followed for protracted periods of time, the incidence of recurrence
plasty for Duodenal Ulcer. Br. Med. J., 1:7, 1972. 5. Herrington, J. L., Jr.: Remedial Operations for Postgastrectomy Syndromes. In Current Problems in Surgery, Chicago, Year Book Medical Publishers, Inc., 1970. 6. Hoerr, S. O.: Comparative Results of Operation for Duodenal Ulcer. Am. J. Surg. 125:3, 1973. 7. Jordan, P. H., Jr. and Condon, R. E.: A Prospective Evaluation of Vagotomy-Pyloroplasty and Vagotomy-Antrectomy for Treatment of Duodenal Ulcer. Ann. Surg., 172:547, 1970. 8. Kennedy, F., Mackay, C. and Bedi, B. S.: Truncal Vagotomy and Drainage for Chronic Duodenal Ulcer Disease: A controlled trial. Br. Med. J. 2:71, 1973. 9. Postlethwait, R. W.: Five Year Follow-up Results of Operation for Duodenal Ulcers. Surg. Gynecol. Obstet., 137:387, 1973. 10. Scott, H. W. Jr., Sawyers, J. L., Gobbel, W. G. Jr. and Herrington, J. L., Jr.: Definitive Surgical Treatment in Duodenal Ulcer Disease. In Current Problems in Surgery, Chicago, Year Book Medical Publishers, Inc., 1968. 11. Weinberg, J. A.: Recurrent Ulceration. In Current Problems in Surgery, Chicago, Year Book Medical Publishers, Inc., 1964.
OF SURGERY
June 1976
No.
6
Vagotomy and Drainage Procedure for Duodenal Ulcer: The Results of Seventeen Years' Experience J. PATRICK O'LEARY, M.D., E. R. WOODWARD, M.D., J. 1. HOLLENBECK, M.D., L. R. DRAGSTEDT, PH.D., M.D.*
During the 10 years prior to January, 1968, 455 duodenal From the Department of Surgery, College of Medicine, ulcer patients were operated upon at the University of Florida University of Florida, Gainesville, affiliated hospitals. The early results were reported in 1969. The Florida, 32610 present study is a followup of the same patients now 7 to 17 years after vagotomy and drainage. Twenty-four per cent were lost to followup. The ulcer recurrence rate was 5.8 per cent. All the recurrent ulcers that were not gastric in location (4.9%) occurred within 5 years after the original operative procedure cedure on 455 patients who have now been followed with a mean of 2.6 years. The gastric ulcers (0.9%) occurred from 7 to 17 years. at a much later date with a mean of 6 years. It is concluded that vagotomy and gastric drainage is a satisfactory modality of Clinical Material therapy for duodenal ulcer. It can be accomplished with an acceptable morbidity and mortality and the long-term recurrence The patients who comprise the population for this rate is low. If recurrences due to incomplete vagotomy do not occur within 5 years, they are unlikely to recur. study were operated upon between October of 1958 and
T HE RESULTS of the accepted modalities of surgical therapy for duodenal ulcer have been generally good. Only small differences exist between the various procedures; however, because of the large number of patients treated each year these differences become significant. Many authors have alluded to the higher incidence of recurrence after vagotomy and a drainage procedure as being its major drawback.147 This paper deals with the results of vagotomy and drainage proPresented at the Annual Meeting of the Southern Surgical Association, December 8-10, 1975, The Homestead, Hot Springs, Virginia. This work has been supported by National Institutes of Health grant number AM-04178. Reprint requests: J. P. O'Leary, M.D., Department of Surgery, Box J-286, College of Medicine, University of Florida, Gainesville, Florida 32610. *
Deceased.
January of 1968. These patients were first reported in the Annals of Surgery in 1969.3 Followup has now been extended to a minimum of 7 years and a maximum of 17 years. In the original study there were 455 patients, seven of whom were lost to followup. In the present study 348 patients were evaluated. Of these, 85 are now dead. Only one of the deaths was related to the patient's ulcer disease and occurred at the time of a subsequent gastric resection. One hundred and seven of the 455 were lost to followup leaving 76% of the original patients accounted for in the study. The demographic data for this group were reported in the previous evaluation. Significant parameters reveal that there was a preponderance of Caucasian versus Negro patients (382/72), males versus females (415/40), skilled and unskilled versus professional and executive individuals (280/67). The age range in the group was from 8 years to 83 years with an average age of 49 years; 45% were 50 years old or older. The population of the present group reflects the increasing age
613
614
O'LEARY AND OTHERS
TABLE 1. Indication for Operation
Elective 401/455 (88%)Patients 1. Intractability 2. Inability to adhere to medical treatment 3. Recurrent hemorrhage previous perforation symptoms of hiatus hernia 4. Obstruction Emergency 54/455 (12%)Patients 1. Hemorrhage 2. Perforation
No. Patients
Per cent
265/401 22/401
66 5
68/401 46/401
17 12
46/54 8/54
85 15
of the group as a whole, but was consistent with the age distribution of the original group. Two hundred and seventy-three (60%) had suffered at least one hemorrhage prior to their surgery and 79 (17%) had a history of previous perforation. Forty-five patients were operated upon as emergencies and 409 (90%) had undergone medical management. Forty per cent of all the patients had coexistent diseases at the time of range
surgery.
The indications for surgery are listed in Table 1. The were done for intractability (66%). The operative mortality was 1% in 401 elective procedures and 2% in 44 emergency procedures. In 416 (91%) a vagotomy and pyloroplasty was the procedure of choice while in 39 (9%) the drainage procedure was a gastroenterostomy. A tube gastrostomy was employed in 94% of the cases (Table 2).
great majority
Followup
Followup was accomplished by direct evaluation in the clinic, home visits, written responses to questionnaires or telephone conversations. In instances where questions arose, the patient's family physician was contacted directly. All patients in this series were followed a minimum of 7 years and some as long as 17 years postoperatively. The average followup was 10 years. Recurrences A standard definition of recurrent ulcer disease was used as described by Weinberg1" i.e.: 1) persistence of ulceration following operation; 2) ulceration in a new site; 3) recurrence after an interval of apparent complete healing; 4) any suspected recurrence of ulceration unless proven not to exist. These are the same criteria used in
the earlier study. In the 257 patients who were evaluated, 6 had developed recurrent duodenal or marginal ulcer and 4 had developed a gastric ulcer. In the group studied, this is an incidence of recurrence of 10 out of 257 or 4%.
Ann. Surg. * June 1976
When the 10 recurrences in this group are added to the 16 recurrences found in the original study, the overall incidence of recurrence is 5.8% (Table 3). Of the 6 patients who developed a duodenal recurrence, 4 had had a vagotomy and pyloroplasty with gastrostomy while two had had a vagotomy and gastroenterostomy. The latent period from the time of surgery to recurrence ranged from one year to 5 years with a mean of 2.6 years. Five of these patients required reoperation. One of the patients with a gastroenterostomy bled 11/2 years after his original operation. He was demonstrated to have another duodenal ulcer; his small gastroenterostomy was taken down and a Finney pyloroplasty fashioned. The other patient with a gastroenterostomy developed a marginal ulcer two years after his original surgery. He was operated upon and an antrectomy with gastroduodenostomy was performed. Both patients are now free of disease. Three of the remaining four patients with recurrent duodenal ulcers have undergone gastric resection. One of these had recurrent hemorrhage while the others had recurrent symptoms. The fourth patient has bled, but has not required surgical intervention. All of these patients had experienced recurrent abdominal pain. In the group of 4 patients who developed a gastric ulcer, one had a vagotomy with gastroenterostomy while the remaining three had a vagotomy and pyloroplasty. The latent period varied from 5 to 8 years with a mean of 6 years. Two of the ulcers were discovered at autopsy. One was described as an acute gastric erosion and occurred in a patient who survived two days after a myocardial infarction. The second was a chronic ulcer found in an elderly man who died of pneumonia. The third was treated with a gastric resection and gastroduodenostomy while the fourth was treated nonoperatively. In this group, two had originally been TABLE 2. Operative Procedure
Primary Vagotomy and pyloroplasty 1. Weinberg 2. Finney Vagotomy and Gastroenterostomy Total Gastrostomy Incidental (120 or 26% patients) Hiatal herniorrhaphy
Cholecystectomy Appendectomy Splenectomy Other
No. Patients
Per cent
416/455 407/416 9/416 39
91
455 428
100 94
48 21 16 6 29
11 5 3 1 6
9
Vol. 183 . NO. 6
VAGOTOMY FOR DUODENAL ULCER TABLE 3. Recurrent Ulcer
3V4 Years
10 Years
Per cent
Suspected
13/443 3/443
23/443 3/443
5.2 .6
TOTAL
16/443
26/443
5.8
Proved
57%
Highly pleased Satisfied Not satisfied Highly dissatisfied Feel better Feel same Feel worse
No. Patients/Average Followup
Overall
615 TABLE 4. Results
30%0 7% 6% 87% 7% 6%
grees was a problem in 40% of patients. Of the 37 asfor pain one intractability, for operated patients who were able to compare it to their prerepeated of one because and with hemorrhage, sociated operative pain, 62% felt that it was the same while 8% this in individuals the of Two bouts of obstruction. felt that it was less severe and 30% felt that it was procedures. gastric group had had previous more severe. Vomiting was not a problem in 86% of the patients. Of Dumping the 14% in whom it was a problem, 3% felt the problem was mild, 4% felt the problem was moderate, and Although there was a significant incidence of patients 7% felt that the problem was severe. Bloating was present complaining of abdominal distress, true "dumping" was in 55% of the patients. It was classified as mild in 14%, relatively infrequent. The dumping syndrome was divided moderate in 24% and severe in 17%. into two major classifications. The first group included Forty-two or 16% of the patients had experienced those who demonstrated the effects of volume shifts after bleeding from the G.I. tract. Seven of these 42 patients the ingestion of a food; this was termed early had apparently rebled from ulcer disease and were listed dumping. The second group included those who de- as recurrences. The rest of the patients bled from other veloped symptoms of hypoglycemia two to 4 hours after parts of the G.I. tract. The most common site of origin eating; this was termed late dumping. was hemorrhoids. All patients who responded positively Eight patients demonstrated early dumping while two to this item were contacted directly or evaluated by their exhibited late dumping. One patient demonstrated some family physician. symptoms of both. The majority of patients conThe majority of the patients, 82%, stated that they felt trolled their symptoms by regulation of their diet. None better while 12% felt that they were the same and 6% felt has required surgical intervention to alleviate these that they were worse. Six of this latter group of 15 exsymptoms. hibited a form of the dumping syndrome.
upon
Diarrhea Diarrhea was present in 16% of the series. The bulk of the patients who responded felt that it was mild, but 5% felt that it was a rather severe problem. Two of the patients had their lives moderated by the presence of this annoying symptom. It was interesting to note that three patients stated the ingestion of antacids diminished the frequency of their diarrhea. Others complained of frequent stools, but true diarrhea was not present.
Subjective Evaluation Patients were asked to answer a standard questionnaire in regard to a variety of different symptoms that could be associated with their operations. Eighty-seven per cent of patients were either highly pleased or satisfied with the results of their surgery while 7% were not satisfied and 5% were highly dissatisfied (Table 4). Despite this apparent generally positive feeling toward the procedure, 53% of patients complained that they were still having some stomach problems (Table 5). Pain of varying de-
Discussion
Morbidity and mortality from vagotomy and pyloroplasty and vagotomy with limited gastric resection have been extensively reported.1.3'4'7-10 In the well-trained hands of the investigators reporting these series the differences in mortality are small, but probably real. In many series mortality after a gastric resection, regardless how small, is 1½2 to 3 times that after a vagotomy and pyloroplasty.6.9 10 These data are gathered from centers where there is great interest in the care and treatment of duodenal ulcer. Although in some of these centers TABLE 5. Subjective Evaluations
Symptoms
None
Mild
7% 60% 3% 86% Vomiting 8% 84% Diarrhea 14% 45% Bloating Yes 53% Stomach Problems Pain
Moderate
21% 4% 3% 24% No 47%
Severe
12% 7% 5%
17%o
Ann. Surg. * June 1976 O'LEARY A,NID OTHERS 616 much of the surgery is done by housestaff, the pro- will steadily increase. This has not been the finding cedures are carefully supervised and experienced in this study. surgical judgment is exercised. When a difficult duoThe recurrence rate of peptic ulcer disease after a denum is encountered, the experienced gastrointestinal vagotomy and drainage procedure is 5.8%. Although surgeon assesses the situation and chooses an alternative the followup is only 76%, comparisons between the to gastric resection. Certainly not all duodenums lend Negro/Caucasion distribution ratio and the shape of the themselves to gastric resection, regardless of how small age distribution curve between the present patient poputhe resection may be. The potential problem resides lation and the original series suggests that a representaat the line of the anastomosis or closure, not during the tive sample has been obtained. actual resection. The reason that the skilled surgeon's All of the recurrences of duodenal ulcer occurred mortality with gastric resection approaches that of a within the first 5 years after surgery with an average vagotomy and drainage procedure is that he avoids po- lapse time of 2.6 years. When a patient developed a tentially lethal problems by selecting out the high risk gastric recurrence, it appeared between 5 and 8 years patient in the operating room. The surgeon who in- postoperatively with an average lapse time of 6 years. frequently faces these problems may not be as adept in All of the patients who developed recurrences that making these decisions. were not gastric ulcers developed them less than 5 years Morbidity is lower after a vagotomy and drainage pro- after their operation. Since all of the patients have now cedure than after a vagotomy and limited gastric re- been followed between 7 and 17 years with the section. Suture line disruption is less likely after a majority being followed more than 10 years, we believe pyloroplasty than after an antrectomy. Likewise, pan- that the vast majority of recurrences after incomplete creatic injury and subhepatic abscess are less likely vagotomy and pyloroplasty will occur within the first 5 after the former than after the latter. If the recon- years. Late recurrences in the form of gastric ulcer are struction after a gastrectomy is a gastrojejunostomy, then less common and have a latent period over 5 years. It the patient is at risk for various postgastrectomy syn- has been our experience that these are often associated dromes which are associated with the jejunal and duo- with unrelated acute illnesses or chronic debilitating denal limbs.5 These are obviated by a vagotomy and diseases. pyloroplasty. Bile gastritis has been reported after a References vagotomy and pyloroplasty, but it is certainly more W. M., Klein, D. and Griffen, W. 0. Jr.: The Role of common after a gastrectomy, especially if a Billroth 1. Bryant, Vagotomy in Duodenal Ulcer Surgery. Surgery, 61:864, 1964. II gastrojejunostomy has been constructed.2 2. Bushkin, F. L., DeFord, J. W., Wickbom, G. and Woodward, E. R.: A Clinical Evaluation of Postoperative Alkaline Reflux In this series approximately 95% of the procedures in Gastritis. 41:88, 1975. the Veterans Administration Hospital and approximately 3. Eisenberg, M.Am.M.,Surg., Woodward, E. R., Carson, T. J. and Drag75% of the procedures in the University Hospital stedt, L. R.: Vagotomy and Drainage Procedure for Duodenal Ulcer: The Results of 10 Years' Experience. Ann. Surg., 170: were performed by resident surgeons. Yet the mortality 317, and morbidity were acceptably low. We feel that the 4. Goligher,1969.J. C., Pulvertaft, C. N., Irvin, T. T., et al.: procedure is relatively simple and can be learned Five-to-Eight Year Results of Truncal Vagotomy and Pyloro-
quickly. As alluded to earlier, although there is only a small difference in the mortality, it is still significantly higher after a gastrectomy than after a vagotomy and drainage procedure. Although this difference is small, because of the large number of individuals operated upon each year the number of lives lost is significant. If a recurrence develops, the patient can be reoperated upon and a resection performed with no greater risk than other surgeons would accept for the primary procedure. The final question then seems to be the difference in the incidence of recurrence in patients after these procedures. It has been postulated that as large series of patients who have had vagotomy and a drainage procedure are followed for protracted periods of time, the incidence of recurrence
plasty for Duodenal Ulcer. Br. Med. J., 1:7, 1972. 5. Herrington, J. L., Jr.: Remedial Operations for Postgastrectomy Syndromes. In Current Problems in Surgery, Chicago, Year Book Medical Publishers, Inc., 1970. 6. Hoerr, S. O.: Comparative Results of Operation for Duodenal Ulcer. Am. J. Surg. 125:3, 1973. 7. Jordan, P. H., Jr. and Condon, R. E.: A Prospective Evaluation of Vagotomy-Pyloroplasty and Vagotomy-Antrectomy for Treatment of Duodenal Ulcer. Ann. Surg., 172:547, 1970. 8. Kennedy, F., Mackay, C. and Bedi, B. S.: Truncal Vagotomy and Drainage for Chronic Duodenal Ulcer Disease: A controlled trial. Br. Med. J. 2:71, 1973. 9. Postlethwait, R. W.: Five Year Follow-up Results of Operation for Duodenal Ulcers. Surg. Gynecol. Obstet., 137:387, 1973. 10. Scott, H. W. Jr., Sawyers, J. L., Gobbel, W. G. Jr. and Herrington, J. L., Jr.: Definitive Surgical Treatment in Duodenal Ulcer Disease. In Current Problems in Surgery, Chicago, Year Book Medical Publishers, Inc., 1968. 11. Weinberg, J. A.: Recurrent Ulceration. In Current Problems in Surgery, Chicago, Year Book Medical Publishers, Inc., 1964.
