Gastric ulcer treated with ulcerectomy, vagotomy, and drainage

Abstract

This is a report of 152 patients with gastric ulcer treated by ulcerectomy, vagotomy, and drainage. In the series, 123 patients were operated on electively and 29 were operated on acutely for bleeding, with operative mortality rates of 1.3% and 6.9%, respectively. The operative mortality rate for the whole series was 2.6%. Of 144 patients followed up, 94 were cured and 25 were improved. The remaining 25 patients were reoperated on, 20 for recurrent ulcer, 2 for early postoperative gastric retention, 2 for dumping and reflux gastritis, and 1 for stenosing ulcer in the esophagus. In the group of 119 successfully treated patients, moderate side effects were observed, including diarrhea in 5.2% and dumping in 8.6%. In 26 patients, the mean reduction of histamine-stimulated or pentagastrin-stimulated acid output was 72.2% when the response to insulin stimulation was 0, 45.1% when the response to insulin was between 0 and 2 mEq acid per hour, and 12.4% when the response was higher. The frequency of positive insulin tests postoperatively was 77.8% among patients with recurrent ulcer, 40% among improved patients, and 10.8% among cured patients. Of 4 patients with ulcer recurrence and negative insulin tests, 3 had gastric retention and 1 hypergastrinemia.

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.…”

“…This is likely to be either very difficult or even impossible [14,23,32,33]. It may be very difficult, first, because the ulcer is high up near the cardia, and as, by our definition, a clamp cannot be placed above it, it needs to be excised free-hand; and second, because the ulcer is likely to be large, excision will result in a long suture line.…”

“…It should, however, be stressed again that excision ofa HGU is difficult or impossible and this was not attempted in our 3 patients. When vagotomy is done, it should generally be a truncal vagotomy rather than a selective gastric or a parietal cell vagotomy, first, because in these often severely ill patients the easiest and most rapid procedure should be chosen; second, the edema, fibrosis, and adhesions incurred by the HGU, which is usually lying on the lesser curvature, makes a selective type of vagotomy difficult or impossible [14,23,32,33], the latter even more so if ulcer excision is contemplated. Clarke et al [19] report good results for truncal vagotomy with ulcer biopsy for HGU in 21 patients.…”

“…The incidence of cases that can be interpreted as missed carcinomas appears to be higher after vagotomy than after gastrectomy [28,30,34,43]. If vagotomy is to be practiced for gastric ulcer, it seems to be wise to excise the ulcer in order to decrease recurrence rates and the incidence of missed cancer [2,17,26,28,32,34,43]. As stated above, ulcer excision in patients with HGU is often difficult, hazardous, and sometimes impossible.…”