Vagotomy and pyloroplasty for gastric ulcers

Abstract

Eighty patients with benign gastric ulcer treated by vagotomy and pyloroplasty in a district general hospital are reviewed. There were no postoperative deaths in the patients undergoing elective surgery but 8 deaths in those undergoing emergency surgery for massive bleeding (38 per cent). Eighty-three per cent of patients had a result that was classed as good or satisfactory. Recurrent gastric ulceration was found in 8 per cent and a tendency to late asymptomatic ulcer recurrence is identified. Careful long term follow-up, including endoscopic re-examination, is advocated for patients undergoing conservative operations for benign gastric ulcer.

High gastric ulcer

“…This high mortality for emergency procedures is also seen in patients with distally placed ulcers. It was 7-40% in patients operated on for bleeding [11,[13][14][15][16][17][18] and 40% for perforation [5], but the mortality can be close to zero even for emergency procedures [19,20]. Also of note was that 8 of 20 of the patients in this report bled severely or perforated their ulcers while on active antiulcer treatment, usually H2-receptor blocking agents.…”

“…One missed carcinoma occurred in each of the 2 groups. From the literature, it appears that malignant ulcers will be left behind more frequently despite adequate biopsy procedures, when the ulcer is not locally excised or removed by gastrectomy [16,[23][24][25]. Patients may, however, present later with carcinoma of the stomach also after the ulcer has been locally excised [26][27][28] and even when a gastrectomy has been performed [20,29] as occurred in one of our patients.…”

“…In all the following procedures it is, therefore, obviously a prerequisite that a malignant ulcer has been reasonably excluded by preoperative gastroscopic biopsies and/or adequate operative biopsies submitted for frozen section pathological studies. Biopsy of the ulcer either endoscopically or at operation is generally considered to be an accurate means of excluding cancer [2,14,16,25,[30][31][32].…”

“…This is based on the rationale that inadequately treating a patient with a cancer, who has a poor prognosis anyway, is a lesser evil than subjecting a patient with a benign ulcer, and a relatively good prognosis, to the high risk of postoperative mortality and morbidity of a total gastrectomy [3,7,31]. Furthermore, the results of a later regastrectomy if the cancer diagnosis is subsequently substantiated are reasonably good [16,26,30]. In addition, in our experience, many HGU's are deeply penetrating so that any attempt at a curative gastrectomy for suspected cancer would be fatuous anyway.…”

“…Although we could find no report in the literature comparing gastrectomy with vagotomy for HGU, there are studies comparing these 2 when used for more distal ulcers [28,30,43]. If one may be allowed to extrapolate these results to the situation under discussion, the following conclusions may be drawn: The mortality and immediate postoperative morbidity of gastrectomy is higher than that of vagotomy [30,44] and this becomes more apparent in the emergency situation [5,16]. The mortality of gastrectomy increases in direct proportion to the height of the resection [20,30].…”