SCIENTIFIC PAPERS
Vagotomy of the Fundic Gland Area of the Stomach without Drainage A Definitive Treatment for Perforated Duodenal Ulcer Paul H. Jordan, Jr, MD, Houston, Texas Sture Hedenstedt, MD, Ektorp, Sweden Ferenc L. Korompai, MD, Houston, Texas G. Lundquist, MD, Ektorp, Sweden
The primary aim of the treatment of perforated duodenal ulcer is to save the patient’s life, and the secondary goal is to treat the patient’s ulcer disease. Those individuals who treat perforated ulcers with nasogastric suction without surgery or with simple closure of the ulcer have emphasized the first principle at the exclusion of the second. Few physicians continue to treat perforated duodenal ulcers by nasogastric suction except in very special circumstances where surgery is contraindicated. Simple closure of an ulcer continues to be widely practiced and is considered by many as the method of choice whenever it can be used. It is also the preferred treatment of perforated acute ulcers by some surgeons who advocate definitive treatment for perforated chronic ulcers. Definitive treatment refers to those procedures that not only deal with the emergency aspects of perforation but also attempt to prevent persistent or recurrent ulcer. This concept is not new for Keetley [1] resected successfully the pylorus in 1902 and Von Haberer [2] subsequently recommended gastric resection as definitive treatment for perforated duodenal ulcer. When truncal vagotomy was introduced, its adoption for treatment of perforated ulcer was slow because of the fear of causing mediastinitis. This complication never materialized and truncal vagotomy combined with antrectomy [3] has been accepted as a method of definitive treatment of perforated duodenal ulcers. Vagotomy and a drainage [4,5] procedure have also been used for this purpose because it was thought that the mortality rate would be lower and that gastric complications would be less From the Departments of Surgery, Baylor College of Medicine and Veterans Administration Hospital, Houston, Texas, and Nacka Sjukhus. Ektorp. Sweden. Reprint requests should be addressed to Paul H. Jordan. Jr. MD, 1200 Moursund Avenue, Houston, Texas 77030.
vokane 131, May 1976
with a simpler procedure. Neither of these potential advantages was realized. A skilled gastric surgeon who is judicious in his selection of patients for definitive surgery can perform either of the above operations with a mortality rate as low as might occur with simple closure [6] when the choice of operation is based on the technical problems related to the duodenum. The benefits of a definitive operation are obvious, for it spares many patients from continued ulcer symptoms and complications of recurrent ulcer. The disadvantage of employing a definitive operation in the treatment of all patients who are acceptable risks after perforation is the fact that a certain percentage of patients who would not have required definitive treatment for ulcer after simple closure may unnecessarily fall heir to unpleasant symptoms that are the consequence of gastric surgery. The number of patients in this category depends on their ages, the duration of their symptoms, and the chronicity of their ulcers. Although these factors are helpful in estimating the number of patients in a given population who will have further trouble with their ulcers after simple closure, it is not possible at the time of perforation to identify with complete accuracy the particular patients who will or will not have subsequent difficulty after simple closure. Conservatively, however, 14 per cent of patients undergoing definitive operation would not have required such treatment [7]. For this reason, it has been difficult for us to recommend definitive therapy for all patients. In our opinion, before a definitive operation can be recommended to all patients who might be expected to tolerate operation, the procedure should be attended with virtually no mortality, it should produce no undesirable gastric complaints, and it should provide protection against recurrent ulcer.
523
Jordan et al
TABLE I
Years
Number of Patients 20-29 13 12
Houston Nacka
TABLE II
30-39
40-49
50-70
2 2
3 4
7 5
1 1
Length of Follow-Up Months
Number of Patients 13 9
Houston Nacka
TABLE III
6-12
13-24
25-36
37-48
3 1
10 3
0 3
0 2
Number of Postoperative Complaints
Dumping Early Late Diarrhea Early satiety Reflux Dysphagia Epigastric distress
TABLE IV
Houston
Houston (n = 13)
Nacka (ll = 9)
0 0 0 0 1 1 1
0 0 0 0 0 0 0
Late Results after Simple Closure and SPV or PCV Number of Patients
Nacka
Methods
Distribution of Patients by Age
13 9
Follow-Up (months) 6to24 6 to 48
Excellent
Good
Fair
Poor
11
2
0
0
9
0
0
0
The excellent clinical results obtained with vagotomy of the fundic gland area of the stomach without a drainage procedure for elective treatment of duodenal ulcer suggested that this procedure might fulfill our requirements for the ideal operation for definitive treatment of perforated duodenal ulcer. This operation has been identified by several different names. At Nacka Sjukhus we prefer selective proximal vagotomy (SPV) and in Houston, parietal cell vagotomy (PCV). We make no claims that we originated the use of this procedure for treatment of perforated duodenal ulcers. Independently, we very early began to use SPV or PCV in the treatment of perforated ulcers and have combined the results of our studies to form the basis of this report.
524
Between September 1969 and October 1974, twelve patients in the Nacka (N) material were suitable for definitive surgery; the first four patients underwent SPV with pyloroplasty. The last eight consecutive patients underwent operation without pyloroplasty. In the Houston (H) material, the first patient underwent operation in 1973. Thirteen consecutive patients who were candidates for definitive surgery and who did not have obstruction underwent PCV without drainage. The age distribution of the patients in the two groups was similar. (Table I.) All patients were males with the exception of three females in the Nacka group. Four of the Nacka and one of the Houston patients were without symptoms prior to perforation. The average length of time between perforation and operation was 9 (N) and 11 hours WI). The operations consisted of closure of the perforation either by sutures or an omental patch followed by SPV or PCV. In some of the patients in the Nacka group, excision of the ulcer was combined with SPV. The longer the time interval between perforation and operation, the more difficult it was to identify the nerves of Latarjet because of chemical peritonitis. The fibrin exudate tended to obscure the vagal branches, but the actual visualization of these fibers was not essential if the dissection along the lesser curvature was kept close to the gastric wall. The technics of performing SPV or PCV reported from the two institutions [8,9] were remarkably similar as was documented by an exchange of visits by the authors between the two institutions. Circumferential section of the longitudinal musculature of the esophagus to ensure division of the network of small vagal branches in the esophageal wall and the use of leucomethylene blue to demonstrate vagal fibers were performed in the Nacka but not in the Houston patients and constituted the major differences in the technics used by the two institutions. Of the twelve Nacka patients, one was studied six months and eight were studied one to four years postoperatively. Three were lost to follow-up. Of the nine patients studied postoperatively, pyloroplasty was performed on two patients and no drainage procedure was performed on seven patients. All thirteen of the Houston patients underwent PCV without a drainage procedure and were studied five months to two years postoperatively. (Table II.) All patients in both groups were hospitalized for follow-up studies.
Results There was no operative mortality. The immediate postoperative course was almost free from complications. One patient in the Houston group required reoperation at eleven days and one at nine months, both for small bowel obstruction. No signs of mediastinitis were found in any case. Nasogastric tubes were removed one to five days after operation. The
The American Journal of Surgery
Perforated Duodenal Ulcer
longer periods of nasogastric suction were sometimes required because of ileus due to chemical peritonitis. The length of hospitalization after operation ranged from six to fifteen days for an average of nine days in the Nacka group and seven to twenty days for an average of eleven days in the Houston group. A solid diet was initiated no later than the fifth day after operation. Upper gastrointestinal roentgenographic findings of the Houston patients at the time of discharge from the hospital revealed normal emptying of barium by each. The clinical symptoms at the time of the patients’ last examination are noted in Table III. At nine months, one patient in the Houston group had mild dumping, but at the time of their last examination no patient in either group had dumping or diarrhea. Early satiety and minimal dysphagia were not uncommon complaints during the first three months after operation but had usually disappeared by six months. In one patient occasional mild dysphagia persisted at his last examination. The first patient, undergoing operation thirty months ago, has had occasional epigastric distress symptoms, suggesting ulcer and requiring antacids. His gastric secretory studies indicated an incomplete vagotomy. Repeated upper gastrointestinal roentgenograms showed that no patient had gastric retention of barium. All patients maintained their weight and strength. A difference in the postoperative secretory responses to insulin hypoglycemia was the major discrepancy in the results between the two groups of patients. None of the Nacka patients had a positive insulin test according to Hollander’s criteria [IO], whereas four patients in the Houston group had a positive test result. This may have been due to the interval between operation and the test, which was longer in the Houston patients compared with the Nacka patients. The late clinical results appear in Table IV. The results were considered excellent in all nine of the Nacka patients. There were eleven excellent results and two good results in the Houston group. Comments
Although this study included only twenty-five patients, it demonstrated that SPV or PCV with preservation of the pylorus can be performed safely in patients with a perforated duodenal ulcer. The follow-up studies were of comparatively short duration and included only twenty patients after SPV or PCV without drainage and two patients after SPV and pyloroplasty. Although this number of patients was inadequate to make an accurate evaluation re-
Voiumel31,MsylS76
garding the frequency of persistent or recurrent ulcers or of annoying symptoms of dumping and diarrhea, the results were comparable to those that have been obtained using SPV or PCV without drainage in the elective treatment of duodenal ulcer. Authors have differed significantly in their estimate of the number of patients who have persistent symptoms after simple closure of perforated duodenal ulcers whether they be acute or chronic. Norberg [l l] found that the duration of symptoms before perforation did not influence the prognosis after simple closure unless the patient had had an earlier diagnosis of an ulcer. Among the patients in his study with a diagnosis of an ulcer before perforation and simple closure, only 16.1 per cent were free from recurrence and 70.6 per cent required reoperation. In other studies, continuing symptoms were reported in 65 to 75 per cent of patients, of whom 35 to 50 per cent required definitive surgical treatment
[W.
Because of the high mortality and recurrence rates associated with simple closure of uncomplicated cases of perforated ulcers, an increasing number of surgeons have begun to perform definitive operations at the time of the perforation. The evolution of definitive treatment for perforated duodenal ulcer has consisted of subtotal gastrectomy, then truncal vagotomy and antrectomy, and finally, vagotomy and a drainage procedure in hopes of achieving a safer operation with fewer postoperative gastric complaints. Unfortunately, vagotomy and drainage did not accomplish this purpose and have not been without undesirable sequelae in some patients. The most serious deterrent to the use of definitive surgery for perforated duodenal ulcer regardless of the type has been the risk of death or complications related to gastric surgery in patients who might not have required definitive surgery after simple closure. The number of patients who would undergo an unnecessary definitive procedure, if such were performed whenever it was considered safe, is difficult to judge. For any group of ulcer patients delineated by specific criteria, it is not difficult to accurately predict the percentage of patients within the group who would require further surgery after simple closure of an ulcer. The prediction of the exact patients within the group subsequently needing definitive surgery is much less accurate. Estimates of the number of patients with perforated duodenal ulcer who do not require more than simple closure of the ulcer range from 86 per cent [ 71 for acute ulcers to 30 per cent [II] for chronic ulcers. Therefore, if definitive treatment is to be used in all patients suitable for more than simple closure, there is need for an
525
Jordan et al
operation that carries virtually no morbidity for those patients who might not have needed a definitive operation but that at the same time provides a reasonable opportunity for eradication of the ulcer diathesis in the much larger number of patients who would have needed a second operation subsequently if only simple closure was performed. Either SPV or PCV without drainage was used to evaluate its potential as safe operation for the definitive treatment of perforated duodenal ulcer without causing symptoms of the same magnitude that occur with conventional methods of definitive treatment. SPV or PCV with simple closure or with pyloroplasty if obstruction is present, in our opinion, is the most physiologic, least destructive, and safest form of definitive therapy available for treatment of perforated duodenal ulcer. Experience with this mocedure bv ourselves 114.151and others 1131for the elective treatment of duodenal ulcers indicates that virtually none of the debilitating symptoms that sometimes follow gastric surgery are associated with its use. Because of our small number of patients and the short time that they have been studied, the absence of recurrent ulcers, thus far, is less convincing evidence in support of SPV and PCV. A recurrence rate of 2.0 per cent in a large series of patients treated electivelv bv PCV and followed two to four years was reported [i3] and suggests that this method of treatment may be highly effective in the prevention of recurrent ulcer. Thus it appears that either SPV or PCV without drainage can be performed as satisfactorily after duodenal ulcer nerforation as it can under elective conditions. This operation provides definitive treatment to the large number of patients who require protection from further ulcer disease, yet at the same time, it will not cause the patients who might not have required definitive treatment the gastric complaints sometimes encountered after other procedures. ”
L
I
>
.
a
Summary
Twelve natients in Sweden and thirteen natients in Houston underwent selective proximal vagotomy or parietal cell vagotomy, respectively, for the treatment of perforated duodenal ulcer. A drainage procedure was performed in four of the former and in none of the latter group of patients. There were no
526
operative complications and no operative deaths. Twenty-two of the patients were followed from six months to four years. No patient had recurrent ulcer, dumping, diarrhea, or other significant gastric symptoms during the follow-up period. At the time of their last follow-up, the results were considered excellent or good in all twenty-two patients. The results of this study suggest that SPV or PCV without drainage may be the method of choice for the definitive treatment of all patients with perforated duodenal ulcer who have no obstruction and no contraindications to an operative procedure of greater magnitude than simple closure.
References
1.
Keetley CB: The surgery of non-malbnant qastric ulcer and perforation.Lance; 1; 884, 1902. 2. Von Haberer H: Zur therapie akuter geschwursperforationen des magens und duodenums in die freie bauchhohle. Wein Klin W&henschr 32: 413, 1919. 3. Jordan GL Jr, DeBakey ME, Duncan JM Jr: Surgical management of perforated peptic ulcer. Ann Surg 179: 628, 1974. 4. Hinshaw 0, Pierandoui JS, Tompson RJ Jr, Carter R: Vagotomy and pyloroplastyfor Derforatedduodenal ulcer. Observations on IsO cases. Am j Surg 115: 173, 1968. 5. Hamilton JE: Vagotomy and pyloroplasty. A safe and desirable operationfor the acute perforated duodenal ulcer. Surgery 63: 1345, 1968. 6. Jarrett F. Donaldson GA: The ulcer diathesis in perforated duodenal ulcer disease. Experience with 252 patients during a 25 year period. Am J Surg 123: 406, 1972. 7. Hadfield JlH, Watkin DFL: Vagotomy in treatment of perforated duodenal ulcer. Br Med J 2: 12, 1964. 8. Hedenstedt S, Lundquist G, Moberg S: Selective proximal vagotomy (SPV) in the treatment of duodenal ulcer. Acfa Chir Stand 138: 591, 1972. 9. Jordan PH Jr: Early results of parietal cell vagotomy without drainage in the treatment of duodenal ulcer. Tex A&d 70: 83, 1974. 10. Hollander F: Laboratory procedures in the study of vagotomy (with particular reference to the insulin test). Gastroenterology 11: 419, 1948. 11. Norberg PB: Results of the surgical treatment of perforated peptic ulcer. A clinical and roentgenological study. Acfa Chir Stand Suppl249, 1959. 12. Nemanich GJ, Nicoloff DM: Perforated duodenal ulcer: longterm follow up. Surgery 67: 727, 1970. 13. Amdrup E, Jensen HE, Johnston D, Walker BE, Goligher JC: Clinical results of parietal cell vagotomy (highly selective vagotomy) two to.four years after operation. Ann Sura 180: 279, 1974. 14. Moberg S, Hedenstedt S: Clinical, secretory and motor effects of selective proximal vagotomy. Acta Chir Scand 141: 203, 1975. 15. Jordan PH Jr: Parietal cell vagotomy without drainage. Early evaluation of results in the treatment of duodenal ulcer. Arch Surg 108: 434, 1974.
The American Journal of Surgery
Vagotomy of the Fundic Gland Area of the Stomach without Drainage A Definitive Treatment for Perforated Duodenal Ulcer Paul H. Jordan, Jr, MD, Houston, Texas Sture Hedenstedt, MD, Ektorp, Sweden Ferenc L. Korompai, MD, Houston, Texas G. Lundquist, MD, Ektorp, Sweden
The primary aim of the treatment of perforated duodenal ulcer is to save the patient’s life, and the secondary goal is to treat the patient’s ulcer disease. Those individuals who treat perforated ulcers with nasogastric suction without surgery or with simple closure of the ulcer have emphasized the first principle at the exclusion of the second. Few physicians continue to treat perforated duodenal ulcers by nasogastric suction except in very special circumstances where surgery is contraindicated. Simple closure of an ulcer continues to be widely practiced and is considered by many as the method of choice whenever it can be used. It is also the preferred treatment of perforated acute ulcers by some surgeons who advocate definitive treatment for perforated chronic ulcers. Definitive treatment refers to those procedures that not only deal with the emergency aspects of perforation but also attempt to prevent persistent or recurrent ulcer. This concept is not new for Keetley [1] resected successfully the pylorus in 1902 and Von Haberer [2] subsequently recommended gastric resection as definitive treatment for perforated duodenal ulcer. When truncal vagotomy was introduced, its adoption for treatment of perforated ulcer was slow because of the fear of causing mediastinitis. This complication never materialized and truncal vagotomy combined with antrectomy [3] has been accepted as a method of definitive treatment of perforated duodenal ulcers. Vagotomy and a drainage [4,5] procedure have also been used for this purpose because it was thought that the mortality rate would be lower and that gastric complications would be less From the Departments of Surgery, Baylor College of Medicine and Veterans Administration Hospital, Houston, Texas, and Nacka Sjukhus. Ektorp. Sweden. Reprint requests should be addressed to Paul H. Jordan. Jr. MD, 1200 Moursund Avenue, Houston, Texas 77030.
vokane 131, May 1976
with a simpler procedure. Neither of these potential advantages was realized. A skilled gastric surgeon who is judicious in his selection of patients for definitive surgery can perform either of the above operations with a mortality rate as low as might occur with simple closure [6] when the choice of operation is based on the technical problems related to the duodenum. The benefits of a definitive operation are obvious, for it spares many patients from continued ulcer symptoms and complications of recurrent ulcer. The disadvantage of employing a definitive operation in the treatment of all patients who are acceptable risks after perforation is the fact that a certain percentage of patients who would not have required definitive treatment for ulcer after simple closure may unnecessarily fall heir to unpleasant symptoms that are the consequence of gastric surgery. The number of patients in this category depends on their ages, the duration of their symptoms, and the chronicity of their ulcers. Although these factors are helpful in estimating the number of patients in a given population who will have further trouble with their ulcers after simple closure, it is not possible at the time of perforation to identify with complete accuracy the particular patients who will or will not have subsequent difficulty after simple closure. Conservatively, however, 14 per cent of patients undergoing definitive operation would not have required such treatment [7]. For this reason, it has been difficult for us to recommend definitive therapy for all patients. In our opinion, before a definitive operation can be recommended to all patients who might be expected to tolerate operation, the procedure should be attended with virtually no mortality, it should produce no undesirable gastric complaints, and it should provide protection against recurrent ulcer.
523
Jordan et al
TABLE I
Years
Number of Patients 20-29 13 12
Houston Nacka
TABLE II
30-39
40-49
50-70
2 2
3 4
7 5
1 1
Length of Follow-Up Months
Number of Patients 13 9
Houston Nacka
TABLE III
6-12
13-24
25-36
37-48
3 1
10 3
0 3
0 2
Number of Postoperative Complaints
Dumping Early Late Diarrhea Early satiety Reflux Dysphagia Epigastric distress
TABLE IV
Houston
Houston (n = 13)
Nacka (ll = 9)
0 0 0 0 1 1 1
0 0 0 0 0 0 0
Late Results after Simple Closure and SPV or PCV Number of Patients
Nacka
Methods
Distribution of Patients by Age
13 9
Follow-Up (months) 6to24 6 to 48
Excellent
Good
Fair
Poor
11
2
0
0
9
0
0
0
The excellent clinical results obtained with vagotomy of the fundic gland area of the stomach without a drainage procedure for elective treatment of duodenal ulcer suggested that this procedure might fulfill our requirements for the ideal operation for definitive treatment of perforated duodenal ulcer. This operation has been identified by several different names. At Nacka Sjukhus we prefer selective proximal vagotomy (SPV) and in Houston, parietal cell vagotomy (PCV). We make no claims that we originated the use of this procedure for treatment of perforated duodenal ulcers. Independently, we very early began to use SPV or PCV in the treatment of perforated ulcers and have combined the results of our studies to form the basis of this report.
524
Between September 1969 and October 1974, twelve patients in the Nacka (N) material were suitable for definitive surgery; the first four patients underwent SPV with pyloroplasty. The last eight consecutive patients underwent operation without pyloroplasty. In the Houston (H) material, the first patient underwent operation in 1973. Thirteen consecutive patients who were candidates for definitive surgery and who did not have obstruction underwent PCV without drainage. The age distribution of the patients in the two groups was similar. (Table I.) All patients were males with the exception of three females in the Nacka group. Four of the Nacka and one of the Houston patients were without symptoms prior to perforation. The average length of time between perforation and operation was 9 (N) and 11 hours WI). The operations consisted of closure of the perforation either by sutures or an omental patch followed by SPV or PCV. In some of the patients in the Nacka group, excision of the ulcer was combined with SPV. The longer the time interval between perforation and operation, the more difficult it was to identify the nerves of Latarjet because of chemical peritonitis. The fibrin exudate tended to obscure the vagal branches, but the actual visualization of these fibers was not essential if the dissection along the lesser curvature was kept close to the gastric wall. The technics of performing SPV or PCV reported from the two institutions [8,9] were remarkably similar as was documented by an exchange of visits by the authors between the two institutions. Circumferential section of the longitudinal musculature of the esophagus to ensure division of the network of small vagal branches in the esophageal wall and the use of leucomethylene blue to demonstrate vagal fibers were performed in the Nacka but not in the Houston patients and constituted the major differences in the technics used by the two institutions. Of the twelve Nacka patients, one was studied six months and eight were studied one to four years postoperatively. Three were lost to follow-up. Of the nine patients studied postoperatively, pyloroplasty was performed on two patients and no drainage procedure was performed on seven patients. All thirteen of the Houston patients underwent PCV without a drainage procedure and were studied five months to two years postoperatively. (Table II.) All patients in both groups were hospitalized for follow-up studies.
Results There was no operative mortality. The immediate postoperative course was almost free from complications. One patient in the Houston group required reoperation at eleven days and one at nine months, both for small bowel obstruction. No signs of mediastinitis were found in any case. Nasogastric tubes were removed one to five days after operation. The
The American Journal of Surgery
Perforated Duodenal Ulcer
longer periods of nasogastric suction were sometimes required because of ileus due to chemical peritonitis. The length of hospitalization after operation ranged from six to fifteen days for an average of nine days in the Nacka group and seven to twenty days for an average of eleven days in the Houston group. A solid diet was initiated no later than the fifth day after operation. Upper gastrointestinal roentgenographic findings of the Houston patients at the time of discharge from the hospital revealed normal emptying of barium by each. The clinical symptoms at the time of the patients’ last examination are noted in Table III. At nine months, one patient in the Houston group had mild dumping, but at the time of their last examination no patient in either group had dumping or diarrhea. Early satiety and minimal dysphagia were not uncommon complaints during the first three months after operation but had usually disappeared by six months. In one patient occasional mild dysphagia persisted at his last examination. The first patient, undergoing operation thirty months ago, has had occasional epigastric distress symptoms, suggesting ulcer and requiring antacids. His gastric secretory studies indicated an incomplete vagotomy. Repeated upper gastrointestinal roentgenograms showed that no patient had gastric retention of barium. All patients maintained their weight and strength. A difference in the postoperative secretory responses to insulin hypoglycemia was the major discrepancy in the results between the two groups of patients. None of the Nacka patients had a positive insulin test according to Hollander’s criteria [IO], whereas four patients in the Houston group had a positive test result. This may have been due to the interval between operation and the test, which was longer in the Houston patients compared with the Nacka patients. The late clinical results appear in Table IV. The results were considered excellent in all nine of the Nacka patients. There were eleven excellent results and two good results in the Houston group. Comments
Although this study included only twenty-five patients, it demonstrated that SPV or PCV with preservation of the pylorus can be performed safely in patients with a perforated duodenal ulcer. The follow-up studies were of comparatively short duration and included only twenty patients after SPV or PCV without drainage and two patients after SPV and pyloroplasty. Although this number of patients was inadequate to make an accurate evaluation re-
Voiumel31,MsylS76
garding the frequency of persistent or recurrent ulcers or of annoying symptoms of dumping and diarrhea, the results were comparable to those that have been obtained using SPV or PCV without drainage in the elective treatment of duodenal ulcer. Authors have differed significantly in their estimate of the number of patients who have persistent symptoms after simple closure of perforated duodenal ulcers whether they be acute or chronic. Norberg [l l] found that the duration of symptoms before perforation did not influence the prognosis after simple closure unless the patient had had an earlier diagnosis of an ulcer. Among the patients in his study with a diagnosis of an ulcer before perforation and simple closure, only 16.1 per cent were free from recurrence and 70.6 per cent required reoperation. In other studies, continuing symptoms were reported in 65 to 75 per cent of patients, of whom 35 to 50 per cent required definitive surgical treatment
[W.
Because of the high mortality and recurrence rates associated with simple closure of uncomplicated cases of perforated ulcers, an increasing number of surgeons have begun to perform definitive operations at the time of the perforation. The evolution of definitive treatment for perforated duodenal ulcer has consisted of subtotal gastrectomy, then truncal vagotomy and antrectomy, and finally, vagotomy and a drainage procedure in hopes of achieving a safer operation with fewer postoperative gastric complaints. Unfortunately, vagotomy and drainage did not accomplish this purpose and have not been without undesirable sequelae in some patients. The most serious deterrent to the use of definitive surgery for perforated duodenal ulcer regardless of the type has been the risk of death or complications related to gastric surgery in patients who might not have required definitive surgery after simple closure. The number of patients who would undergo an unnecessary definitive procedure, if such were performed whenever it was considered safe, is difficult to judge. For any group of ulcer patients delineated by specific criteria, it is not difficult to accurately predict the percentage of patients within the group who would require further surgery after simple closure of an ulcer. The prediction of the exact patients within the group subsequently needing definitive surgery is much less accurate. Estimates of the number of patients with perforated duodenal ulcer who do not require more than simple closure of the ulcer range from 86 per cent [ 71 for acute ulcers to 30 per cent [II] for chronic ulcers. Therefore, if definitive treatment is to be used in all patients suitable for more than simple closure, there is need for an
525
Jordan et al
operation that carries virtually no morbidity for those patients who might not have needed a definitive operation but that at the same time provides a reasonable opportunity for eradication of the ulcer diathesis in the much larger number of patients who would have needed a second operation subsequently if only simple closure was performed. Either SPV or PCV without drainage was used to evaluate its potential as safe operation for the definitive treatment of perforated duodenal ulcer without causing symptoms of the same magnitude that occur with conventional methods of definitive treatment. SPV or PCV with simple closure or with pyloroplasty if obstruction is present, in our opinion, is the most physiologic, least destructive, and safest form of definitive therapy available for treatment of perforated duodenal ulcer. Experience with this mocedure bv ourselves 114.151and others 1131for the elective treatment of duodenal ulcers indicates that virtually none of the debilitating symptoms that sometimes follow gastric surgery are associated with its use. Because of our small number of patients and the short time that they have been studied, the absence of recurrent ulcers, thus far, is less convincing evidence in support of SPV and PCV. A recurrence rate of 2.0 per cent in a large series of patients treated electivelv bv PCV and followed two to four years was reported [i3] and suggests that this method of treatment may be highly effective in the prevention of recurrent ulcer. Thus it appears that either SPV or PCV without drainage can be performed as satisfactorily after duodenal ulcer nerforation as it can under elective conditions. This operation provides definitive treatment to the large number of patients who require protection from further ulcer disease, yet at the same time, it will not cause the patients who might not have required definitive treatment the gastric complaints sometimes encountered after other procedures. ”
L
I
>
.
a
Summary
Twelve natients in Sweden and thirteen natients in Houston underwent selective proximal vagotomy or parietal cell vagotomy, respectively, for the treatment of perforated duodenal ulcer. A drainage procedure was performed in four of the former and in none of the latter group of patients. There were no
526
operative complications and no operative deaths. Twenty-two of the patients were followed from six months to four years. No patient had recurrent ulcer, dumping, diarrhea, or other significant gastric symptoms during the follow-up period. At the time of their last follow-up, the results were considered excellent or good in all twenty-two patients. The results of this study suggest that SPV or PCV without drainage may be the method of choice for the definitive treatment of all patients with perforated duodenal ulcer who have no obstruction and no contraindications to an operative procedure of greater magnitude than simple closure.
References
1.
Keetley CB: The surgery of non-malbnant qastric ulcer and perforation.Lance; 1; 884, 1902. 2. Von Haberer H: Zur therapie akuter geschwursperforationen des magens und duodenums in die freie bauchhohle. Wein Klin W&henschr 32: 413, 1919. 3. Jordan GL Jr, DeBakey ME, Duncan JM Jr: Surgical management of perforated peptic ulcer. Ann Surg 179: 628, 1974. 4. Hinshaw 0, Pierandoui JS, Tompson RJ Jr, Carter R: Vagotomy and pyloroplastyfor Derforatedduodenal ulcer. Observations on IsO cases. Am j Surg 115: 173, 1968. 5. Hamilton JE: Vagotomy and pyloroplasty. A safe and desirable operationfor the acute perforated duodenal ulcer. Surgery 63: 1345, 1968. 6. Jarrett F. Donaldson GA: The ulcer diathesis in perforated duodenal ulcer disease. Experience with 252 patients during a 25 year period. Am J Surg 123: 406, 1972. 7. Hadfield JlH, Watkin DFL: Vagotomy in treatment of perforated duodenal ulcer. Br Med J 2: 12, 1964. 8. Hedenstedt S, Lundquist G, Moberg S: Selective proximal vagotomy (SPV) in the treatment of duodenal ulcer. Acfa Chir Stand 138: 591, 1972. 9. Jordan PH Jr: Early results of parietal cell vagotomy without drainage in the treatment of duodenal ulcer. Tex A&d 70: 83, 1974. 10. Hollander F: Laboratory procedures in the study of vagotomy (with particular reference to the insulin test). Gastroenterology 11: 419, 1948. 11. Norberg PB: Results of the surgical treatment of perforated peptic ulcer. A clinical and roentgenological study. Acfa Chir Stand Suppl249, 1959. 12. Nemanich GJ, Nicoloff DM: Perforated duodenal ulcer: longterm follow up. Surgery 67: 727, 1970. 13. Amdrup E, Jensen HE, Johnston D, Walker BE, Goligher JC: Clinical results of parietal cell vagotomy (highly selective vagotomy) two to.four years after operation. Ann Sura 180: 279, 1974. 14. Moberg S, Hedenstedt S: Clinical, secretory and motor effects of selective proximal vagotomy. Acta Chir Scand 141: 203, 1975. 15. Jordan PH Jr: Parietal cell vagotomy without drainage. Early evaluation of results in the treatment of duodenal ulcer. Arch Surg 108: 434, 1974.
The American Journal of Surgery
