Long-term results of vagotomy and pyloroplasty in the treatment of gastric ulcer disease.

Two hundred thirteen patients were evaluated to establish the efficacy of vagotomy and pyloroplasty in the treatment of benign gastric ulcer disease. These patients underwent operation between the years 1960 to 1973. Ten patients (5%) were found to have occult gastric malignancies and four of these patients (40%) were cured after resectional therapy. Nineteen patients underwent pyloroplasty without vagotomy, and these patients were ultimately excluded from the study in view of the frequency (26%) of ulcer recurrence. The operative mortality rate was 8.4% overall (1.5% when related to elective operations and 22% of the operative deaths following emergent procedures). Eighty-eight percent of the patients were followed until death or for a minimum of 10 years. Recurrent ulcer disease was confirmed in 11% of the patients. Severe postoperative sequelae were encountered in 3% of the patients for a total failure rate of 14% at 10 years. Recurrences and postoperative sequelae were both more common in women and in those patients who underwent operation for intractability. Vagotomy with pyloroplasty is considered an acceptable alternative operation in the management of patients with benign gastric ulcer disease. It is most applicable in the high-risk patient who requires operative intervention emergently and, in this circumstance, a decreased mortality rate can be demonstrated and ulcer recurrence is unlikely (2%).

Trends in the surgical management of duodenal ulcer. A fifteen year study.

The number of patients undergoing definitive duodenal ulcer operation at Charlotte Memorial Hospital and Medical Center declined by 75 percent from 1971 to 1985. The percentage of women making up the total study population increased to 40 percent in the period from 1981 through 1985. Average patient age also increased. Fewer gastric resections are now being performed and emergency operations are becoming more frequent, with bleeding being the most common indication. Splenic lacerations requiring splenectomy in patients undergoing vagotomy occurred in 3.1 percent of the study population during the 15 year study. The overall mortality rate for elective operations was 1.5 percent and for emergency operations, 17.2 percent. The incidence of acute duodenal ulcer perforation increased during this 15 year study. Duodenal ulcer operations have changed in number and in type as the manifestations of the disease have become altered by trends that began in the mid 1950s and became exaggerated by more effective ulcer therapy.

Elective treatment of bleeding varices with the Sugiura operation over 10 years.

A 10-year experience with the devascularization operation described by Sugiura is reported here. The operation was performed electively in 100 patients in whom it was not possible to place a shunt, all of whom had different kinds of hepatopathies (63 Child's A, 32 Child's B, and 5 Child's C). In 15 patients, the procedure was done in one stage (6% operative mortality, 1 patient), and, in 51, it was performed in two stages. Eight deaths were recorded in the 63 patients of the Child's A group, with a total of 111 operations. The operative mortality rate for this group was 12% and, as related to the number of operative procedures, 7% (8 of 111 operations). Seventeen patients were not considered for a second stage. Rebleeding in the early postoperative period was 4% and at long-term 6%. Incapacitating encephalopathy was found in 2 of the 71 surviving patients (3%). Survival (as determined by Kaplan-Meier tests) was 75% (1 year), 70% (5 years), and 69.2% (10 years). Six esophageal fistulas were observed secondary to transection. The Sugiura operation is an excellent complement to the therapeutic armamentarium used to treat portal hypertension, with low rebleeding and encephalopathy rates.

Parietal cell vagotomy.

Although long-term follow-up data have not been obtained, it appears that parietal cell vagotomy for the treatment of intractable duodenal ulcer is withstanding the test of time. Operative mortality and morbidity are low, as is the incidence of side effects. The majority of patients who have a recurrent ulcer improve with medical therapy, and only a minority require reoperation.

Complications of vagotomy and pyloroplasty.

Vagotomy and pyloroplasty are associated with technical complications, the most important being rupture of the esophagus, splenic injury, leak at the pyloroplasty, and intra-abdominal bleeding. This operation can also be associated with other complications including epigastric fullness, dysphagia, vomiting of food, bilious vomiting, dumping, and diarrhea. The historical background and specific complications of each procedure are discussed.

Surgical treatment of peptic ulcer disease before and after introduction of H2 blockers.

This retrospective study was undertaken to determine if the advent of H2 blockers has altered the surgical treatment and outcome of patients with peptic ulcer disease (PUD). The records of patients having surgery for PUD at Butterworth Hospital, Grand Rapids, Michigan, from 1971-73 (Group 1) and 1981-83 (Group 2) were reviewed. Data recorded included patient and disease characteristics, surgical procedures, morbidity, and mortality. There was a significant difference in mean age: 54 years in Group 1 and 60 years in Group 2. Group 2 had a higher incidence of concomitant medical illnesses. Indications for operation were predominantly of an emergent nature in Group 2, with a marked decline in elective surgeries from 75 per cent to 55 per cent. There was a 15 per cent incidence of nonsurgical complications in Group 2, as opposed to 9 per cent in Group 1. This study demonstrates that the use of H2 blockers and changes in patient characteristics have altered the surgical treatment and outcome of patients with PUD.

Management of benign, giant gastric ulcers.

Giant gastric ulcers (greater than 3 cm in diameter) have traditionally been considered to be refractory to medical therapy and were commonly thought to initially appear as life-threatening hemorrhage requiring emergent operative therapy. This study was undertaken to evaluate the results of medical and surgical treatment of benign, giant gastric ulcers and the validity of these traditional teachings. A retrospective review of 44 patients with giant gastric ulcers was performed to evaluate the results of medical and surgical therapy at Hartford Hospital (Hartford, CT). The majority of these patients received medical therapy. Over 57 per cent received only medical therapy, while 25 per cent received primary, operative therapy. Contrary to popular belief, the authors found that patients who received initial medical therapy did not have high morbidity or mortality rates. Therefore, while the necessity of early surgical intervention following perforation or in patients with signs of hemorrhagic shock can not be refuted, the authors conclude that medical therapy of benign, giant gastric ulcers is often effective and not unduly hazardous. Giant gastric ulcers, in and of themselves, are not an indication for surgery.

[Vagotomy for the surgical treatment of severe gastroduodenal hemorrhages]. / Die Vagotomie im Konzept zur chirurgischen Behandlung schwerer gastroduodenaler Blutungen.

24 patients (8 female, 16 male) with severe gastroduodenal haemorrhage were treated by vagotomy; in 17 cases highly selective vagotomy was performed, in 3 case truncal vagotomy + pyloroplasty and in 4 patients vagotomy was combined with excision or purse-string suture of the ulcer. Treatment was effective in 23 patients, without recurrence of haemorrhage. In 19 patients vagotomy not only curbed the bleeding but provided definitive therapy (Visick I-II); 4 patients died (mortality rate 16%).

Conservative surgery for bleeding duodenal ulcer--vagotomy and pyloroplasty.

50 unselected cases of bleeding duodenal ulcer were treated by vagotomy and pyloroplasty with suturing of the bleeding vessels. The operative mortality was 8% of which recurrent haemorrhage accounted for 6% of the patients. The operative mortality was related to advanced age, severity of bleed and associated medical illnesses. Vagotomy-pyloroplasty with suture ligation is technically easy to perform for bleeding duodenal ulcer and has a low incidence of recurrent haemorrhage.

[Truncal vagotomy in duodenal ulcer (author's transl)]. / La vagotomie tronculair dans l'ulcére duodénal

Since 1961, the authors have treated 369 patients for a duodenal ulcer. Emergency operation was performed in 69 cases (mortality: 7.2 percent) and elective operation in 300 (mortality: 0.86 percent. Procedures associated truncal vagotomy to hemigastrectomy (257 cases), to pyloroplasty (85 cases) or to gastroenterostomy (27 cases). Three hundred and thirty-nine patients were followed for an average of 8 years. The authors preferred truncal vagotomy associated to hemigastrectomy. This yielded excellent long term results (Visick I) in 89 percent of cases (221 out of 246 reviewed cases), with a very low mortality rate (3 out of 257 or 1.2%) and without known recurrence. (Acta chir. belg., 1976, 75, 294-305).

[Immediate and late results of surgical alternatives in the treatment of non-resectable duodenal ulcers (author's transl)]. / Resultados imediatos e tardios de operações em que não resseca a úlcera duodenal (vagotomia e gastrojejunostomia ou antrectomia com exclusão a finsterer), em "duodenos difíceis".

The authors present 69 patients with duodenal ulcer considered as non-resectable ("difficult duodenum"). Troncular vagotomy associated with gastrojejunostomy (VTGE) were performed in 26 cases. This surgical approach was chosen for patients with advanced age, poor general condition and, obesity. When local conditions such as deformity, post-bulbar ulcer and penetrating ulcers were present, troncular vagotomy with antrectomy and Finsterer exclusion (VTAF) was the procedure of choice (43 cases). The incidence of duodenal fistula during the hospital stay was high (6,9%) in the VTAF group but the mortality rate was low, as oposed to the high mortality rate after VTGE. This is in agreement with other authors. Regarding the late results (follow-up for over 1 year in 58.3% of the VTGE group and, 70.5% of the VTAF group) a recurrence rate of 16.6% was observed in the VTGE group and, none in the CTAF group. The authors conclude that in the non-resectable duodenum, the procedure of choice is troncular vagotomy with antrectomy and Finsterer exclusion. Troncular vagotomy and jejunostomy should be considered as an alternative and, performed only in obese patients, over the age of 65 and in poor general condition.

[Truncal vagotomy in the surgical management of bleeding duodenal ulcer. Report of 50 cases (author's transl)]. / Place de la vagotomie tronculaire avec hémostase locale dans le traitment de l'ulcère duodénal hémorragique. A propos de 50 observations.

To control hemorrhage and eliminate the ulcerogenic mechanism, some surgeons have favored gastric resection and others have preferred the more conservative approach of a vagotomy. The analysis of our 50 cases has shown a high frequency of hemorrhage by arterial erosion. All the patients have been treated by transfixing the ulcer with a local suture, associated with a truncular vagotomy and a gastric drainage, the global mortality rate was 26%. The mortality rate in the group of patients with massive bleeding forcing emergency operation is 33%. No death was observed in the group of patients where bleeding was controlled firstly by non operative measures and operated on later. The patient's chances of survival are markedly improved in the group of younger patients. The analysis of literature have shown that the incidence of rebleeding is the same following vagotomy or partial gastrectomy. The post operative mortality rates after these two types of emergency operative procedures are also quite similar. In conclusion, direct ligation of the ulcer base in massive bleeding, coupled with vagotomy, seems to be the operation of choice.

[Perforation of gastroduodenal ulcers. Therapeutic trends. Apropos of 284 cases]. / Perforation des ulcères gastro-duodénaux. Orientation thérapeutique. A propos de 284 cas

The authors analyse retrospectively 284 case records of perforation of gastric and duodenal ulcers treated between 1961 and 1972 and, from a study of the literature, the authors attempt to draw up prognostic factors which permit one to apply to this complication of ulcer disease, the most efficient short and long-term treatment.

[Perioperative mortality for perforated duodenal and gastric ulcer--analysis of 226 patients]. / Smiertelnosc okolooperacyjna w przedziurawionym wrzodzie dwunastnicy i zoladka--analiza 226 chorych.

Between 1988 and 1997 in 226 patients (169 males--75.2% and 57 females--24.8%) surgical treatment was performed due to duodenal ulcer perforation (205 cases--90.7%) or gastric ulcer perforation (21 cases--9.3%, including 3 cases of perforated gastric cancer). Mean age was 51.5 years (19-94 years). In perforated duodenal ulcer the main procedure was truncal vagotomy with pyloroplasty performed in 95.6%, and simple ulcer suture in 4.4%. In perforated gastric ulcer the main procedure was Billroth I (Rydygier) stomach resection performed in 76.18%, and simple ulcer suture in 23.82%. A group of patients who died in perioperative period (29 cases--12.8%) was selected and compared to a group of others regarding age, sex, smoking, alcohol abuse, time elapsing between first symptoms and surgical treatment, use of NSAIDs, location and size of perforation hole, type of surgical procedures. On that basis 4 risk factors of disease in perioperative period due to perforated ulcer surgery were appointed: 1. Age--mean age of patients who died was 67 years (vs. 48.9 years among successfully treated), perioperative mortality in patients over 60 years old was 35.4%, and in patients over 70 years old was 50%). 2. Presence of three or more coexisting diseases--54.54% risk of disease (vs. 2.5% in patients with less than three or without coexisting diseases). 3. Delay in surgical treatment over 24 hours--48.15% of diseases vs. 7.04% in patients undergoing surgery within the first 24 hours following perforation. 4. Septic shock--80% of diseases.

[Vagotomy in surgical treatment of duodenal ulcer]. / Rol' i mesto vagotomii v khirurgicheskom lechenii iazvennoi bolezni dvenadtsatiperstnoi kishki.

Results of organo-saving operations in 807 patients (72% men, 28% women) with duodenal ulcers were analyzed. Bilateral truncal vagotomy (with pyloro-, duodenoplasty, gastroenterostomy, gastroduodenostomy, economical stomach resection) were performed in 27.1% patients, selective--in 1.4%, selective proximal--in 65.5%, anterior selective and posterior truncal vagotomy--in 6.0%. Lethality was 1.6%, long-term results were excellent and good in 75.6% cases. Satisfactory results were seen in 8.6% patients, bad results--in 15.8%.

[Vagotomy in the surgery of perforated pyloroduodenal ulcer]. / Vagotomiia v khirurgii probodnykh piloroduodenal'nykh iazv.

Under analysis are results of the surgical treatment of 300 patients with perforating pyloroduodenal ulcers. The correct selection of patients for the operation gives best nearest and especially long-term results of vagotomy with antrum resection. The amount of recurrences after a simple suturing of the ulcer in 164 patients was 50%, while after vagotomy with/without various draining operations it was 3.7%. Postoperative lethality after vagotomy was not great, long-term results being considerably better than after the operations of simple suturing the ulcer.