Acid secretion in relation to recurrence of duodenal ulcer after vagotomy and drainage

Abstract

The acid secretory responses of patients with recurrent ulcer after vagotomy and drainage have been compared retrospectively with those of patients with a positive insulin test but no recurrent ulcer and with those of patients with a negative insulin test. Patients with recurrent ulcer were on average 10 years younger than patients with an incomplete vagotomy but no recurrence, although their preand postoperative acid secretory responses were similar. Insulin tests were unreliable when performed less than 3 months after vagotomy. The only possible criterion by which recurrent ulceration could be predicted was a postoperative reduction in the peak acid output after pentagastrin of less than 60 per cent. Equal numbers of patients with ‘early’ and ‘late’ positive responses to insulin developed a recurrent ulcer. Routine postoperative insulin tests may be helpful in assessing the efficiency of the vagotomist but are of limited prognostic value. The chief value of postoperative insulin tests appears to be in the diagnostic evaluation of postvagotomy dyspepsia.

Gastric acid secretion and risk of recurrence of duodenal ulcer within six to eight years after truncal vagotomy and drainage

“…The study of Cowley et al (1973) is not comparable to the present one, and is not suitable for the demonstration of possible relationships between recurrence and gastric acid secretion because the patients were selected beforehand by their Hollander responses. Nevertheless, a reduction in PAO of 60% was found to have discriminatory ability.…”

“…Clark, Murray, Slessor, and Wyllie (1964) found that the augmented histamine test was of no use in predicting the risk of recurrence after vagotomy, but this conclusion was founded on an incomplete follow up of only 149 men and women with 'complete vagotomies', including six recurrences. Cowley, Spencer, and Baron (1973) also found that the preoperative histamine test was useless in predicting recurrence in duodenal ulcer patients, selected by means of postvagotomy insulin test results.…”

Where is your vagotomy incomplete? Observations on operative technique

“…Although the Hollander test is open to criticism and different interpretations, Johnston et al (1967) found that there does seem to be a correlation between an early positive Hollander test soon after the operation, later recurrent ulceration and the finding of significant vagal fibres at reoperation, at least after vagotomy and drainage. On the other hand, Cowley et al (1973) found that the Hollander test performed soon after operation was unreliable and concluded that the only criterion that ensured against recurrent ulcer was a reduction in postoperative peak acid output of 60 per cent or more, even if the insulin test was positive. This implies that the vagotomy has been 'adequate' if not complete.…”