Vagotomy or gastrectomy for elective treatment of benign gastric ulceration?

Greenall, Michael J.; Lehnert, Thomas

doi:10.1007/bf01403845

Cited by 6 publications

(9 citation statements)

References 48 publications

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“…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].…”

Section: Discussionmentioning

confidence: 99%

“…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]. The long-term morbidity in the form of postgastrectomy and postvagotomy symptoms is not very different in the 2 procedures [28,30,44].…”

Section: Total Gastrectomymentioning

confidence: 98%

“…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.…”

Section: Total Gastrectomymentioning

confidence: 99%

“…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].…”

Section: Total Gastrectomymentioning

confidence: 99%

“…The mortality of gastrectomy increases in direct proportion to the height of the resection [20,30]. The long-term morbidity in the form of postgastrectomy and postvagotomy symptoms is not very different in the 2 procedures [28,30,44]. The recurrent ulcer rates are higher after vagotomy than after gastrectomy [28,30,44].…”

Section: Total Gastrectomymentioning

confidence: 99%

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High gastric ulcer

1987

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Fifty-six patients with high gastric ulcers were studied retrospectively. There were 38 women and 18 men. The mean age was 66 years. Findings were: 25% had ulcer histories of more than 5 years; 45% had illnesses in other systems making them poor operative risks; 34% were taking ulcerogenic drugs, and 36 % were on antiulcer treatment prior to surgery; 43% presented with severe bleeding, 16% with perforation, and 2 patients had simultaneous bleeding and perforation; 38% had deeply penetrating ulcers and many ulcers were very large; 7 patients had ulcers in hiatus hernias. Sixty-three percent of the procedures were emergencies. Half of the operations were nonresective, with or without vagotomy. The other half were gastric resections of various types. The overall mortality rate was 18%, but the mortality rate was 24% for emergency procedures and 9% for elective ones. The highest mortality rate, 45%, occurred after emergency resective procedures. Vagotomy did not increase postoperative mortality when added to a nonresective procedure. Beside the 10 patients who died, 6 others developed severe postoperative complications, usually respiratory failure or suture line leakage. Follow-up of between 6 months and 12 years (average 3 years) was possible in 55% of the patients. Two developed recurrent ulcers and 2 had overlooked gastric carcinomas. An approach of management for high gastric ulcer is outlined recommending a Pauchet operation for good-risk patients, and vagotomy and drainage for old and frail patients. Medical treatment should be pursued as long as possible to avoid an often hazardous operation.

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Section: Discussionmentioning

confidence: 99%

Section: Total Gastrectomymentioning

confidence: 98%

Section: Total Gastrectomymentioning

confidence: 99%

Section: Total Gastrectomymentioning

confidence: 99%

Section: Total Gastrectomymentioning

confidence: 99%

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High gastric ulcer

1987

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Recurrence after proximal gastric vagotomy for gastric, pyloric, and prepyloric ulcers

Heberer

Teichmann

1987

World j. surg.

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Results after proximal gastric vagotomy (PGV) with ulcer excision for gastric ulcer type I (according to Johnson) show recurrence rates similar to those for duodenal ulcer. In the European Multicenter Trial with 71 patients, symptomatic recurrence was 7.9% at 5 years and the total recurrence (including asymptomatic recurrences) was 17.5%. Recurrent ulcers are mainly gastric ulcers. Treatment of recurrence is, initially, always conservative with antacids or H2-receptor blockers. From 19 patients with recurrent ulcer after PGV with ulcer excision for gastric ulcer type I reported from 3 prospective trials, 12 were managed conservatively. The operative procedure of choice for recurrence was partial gastric resection with a Billroth I or Billroth II reconstruction. Favorable results for this type of gastric ulcer after PGV may be explained by maintenance of gastric continence for solids, reduction of duodenogastric reflux and of postoperative gastritis. Preoperatively and intraoperatively, malignancy has to be excluded by multiple biopsies and frozen sections. Combined gastric and duodenal ulcers (gastric ulcer type II) may also he treated by PGV in controlled trials so that more data will be available for that rare type of ulcer. Recurrence rates after PGV for pyloric and prepyioric ulcers (gastric ulcer type III) are significantly higher than those for gastric ulcer type I or duodenal ulcers. After 5 years, recurrence rates of 16.4-35% are reported. This may be due to gastric retention, which is a common feature in patients with prepyloric ulcers. In fact, selective gastric vagotomy and drainage or vagotomy and antrectomy give significantly better results. The operation rate for recurrent ulcers after pyloric and prepyloric ulcers following PGV is about 25% because of pyloric stenosis. It is concluded that PGV and ulcer excision seem to be suitable for gastric ulcer type I and probably for type H. Pyloric and prepyloric ulcers should no longer be treated by PGV alone because of high recurrence rates. A drainage procedure should be added. In general, the operation should be performed by experienced surgeons since recurrence rates depend on the number of surgeons involved in cliulcal trials.It is well established that the only significant postoperative morbidity following proximal gastric vagotomy without pyloroplasty (PGV) for gastroduodenal ulcer disease is ulcer recurrence [1][2][3][4]. Virtually 5 years after PGV, the Visick grade pattern is almost identical with that of blood donors serving as healthy controls [5]. PGV without a drainage procedure was first introduced for treatment of gastric ulcers by Johnston et al. [6]. To evaluate the results of PGV for benign gastric ulcer disease, it is absolutely mandatory to define the type of the

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