Surgical Treatment of Peptic Ulcer

Victor A. Silberman, MD, and John H. Winkley, MD, Los Angeles

THE WIDE range of opinion regarding to eat three full meals a day, difficulty in
the surgical treatment of peptic ulcer contin- maintaining weight, and the development of
ues to challenge the surgeon's acumen in se- macrocytic, hypochromic anemia. Dumping
lecting an operation for the individual pa- follows 5% to 10% of elective procedures.
tient. Many procedures have been shown to Published operative death rates have ranged
permit recurrent ulceration, and some to from 1.3% to 4%.1-5 Among 58 patients
lead to complications as serious as the origi- with measured 65% to 75% gastrectomy for
nal disease. It also becomes obvious to the duodenal ulcer, followed by Wheeler et al6
surgeon early in his experience that ulcer for periods averaging 4y2 years, recurrence
patients do not fall into a single category, was noted in 4%. In a few patients with
and that the same procedure cannot be rec- 75% to 90% resections, studied by the same
ommended for all. The only rule that is gen- observers, the recurrence rate was 3%, but
erally applicable is that vagotomy should be there was a higher incidence of weight loss,
included as a fundamental step in all opera- fatigue, diarrhea, and postprandial symp¬
tions for peptic ulcer. toms. The authors emphasized that there is
Searching for factors significant to choice a general tendency to overestimate the
among the available techniques, we have amount of stomach that has been removed;
studied retrospectively 527 of the 664 pa- and they expressed the opinion that a more
tients on whom operation for peptic ulcer conservative resection combined with vagot¬
disease was performed during the ten years omy is the operation of choice.
1955-1964 by various members of the surgi- Pyloroplasty, Gastrojejunostomy.—The
cal staff of the Kaiser Foundation Hospital, advantages of pyloroplasty over gastroenter¬
Los Angeles. In considering our findings, we ostomy, as outlined by Kay and Cox7 are:
have also analyzed relevant observations (1) the antrum remains in the acid stream,
published by others during the last few preserving the acid inhibitory mechanism
years. and allowing satisfactory mixing of food
with digestive juices; (2) pyloroplasty per¬
Evaluation of Available Procedures mits direct suture ligation of the bleeding
point in cases of duodenal ulcer and inspec¬
Subtotal Gastrectomy.—Subtotal (65 to tion of the duodenum in doubtful cases; (3)
75%) gastrectomy effectively ablates the an¬ it is technically simple and rarely leads to
tral phase of gastric secretion and the parie¬ complication; and (4) gastrojejunostomy
tal cell mass of the stomach, but introduces has been shown in animals to be ulcerogen-
the risks of duodenal stump leak, inability ic; it creates a circuital passage
through
Submitted for publication Dec 18, 1967.
which ingested food, after having entered
From the Department of Surgery, Southern Cali- the duodenum from the stomach, reenters
fornia Permanente Medical Group, Kaiser Founda- the stomach by way of the
tion Hospital, Los Angeles. gastrojejunal sto¬
Reprint requests to 1526 N Edgemont St, Los ma. The resultant antral stimulation causes
Angeles 90027 (Dr. Silberman). further gastrin production. Where scarring

Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/13/2015

 and inflammation render pyloroplasty infeas- Since truncal vagotomy has been reported
ible, or where there is distal duodenal ob¬ to have untoward effects on the gallbladder,
struction as by a postbulbar ulcer, gastroje¬ pancreas, small intestine, and right side of
junostomy should be substituted. colon, selective vagotomy has been in¬
the
Among recently developed refinements of troduced within the past five years.5 Howev¬
pyloroplasty are the one-layer closure of er, published data do not conclusively show
Weinberg,8 and inclusion of the ulcer in the that this refinement has merit, and the pos¬
gastroduodenotomy. The incidence of dump¬ sibility of incomplete vagotomy, leading to
ing has been reported to be lower after therapeutic failure of the surgical procedure,
pyloroplasty than after gastrojejunostomy must be weighed against the potential side
with or without resection. At the University effects of truncal vagotomy. Thus, Nielsen14
of Michigan Medical Center, according to reported that after truncal vagotomy the
Fry and Thompson,9 the only operation gallbladder becomes dilated and sluggish,
now used for duodenal ulcer is the Finney and that the incidence of cholelithiasis was
pyloroplasty with selective vagotomy. Re¬ higher than in controls. Dragstedt,15 taking
sults have been excellent. In a ten-year issue with this conclusion, found no increase
study of 140 cases, the incidence of ulcer re¬ in the incidence of gallstone formation
currence was 3.1%; of stenosis necessitating among vagotomy patients observed for long
surgical correction, 4.7%. Incomplete vagot¬ periods. He pointed out that contraction of
omy was confirmed by the Hollander test in the gallbladder is mediated by cholecystokin-
4% to 5%. in, a hormone released by the duodenal
Antrectomy, Hemigastrectomy.—The com¬ mucosa in response to a fatty meal, and that
bination of antrectomy or hemigastrectomy stasis and dilatation do not occur after va¬
with vagotomy has been advocated by many gotomy. Stool fat has been shown to in¬
as the ideal operation.1·10 The Billroth I crease in patients having either truncal or
anastomosis frequently used in these pro¬ selective vagotomy,18 reflecting a defect in
cedures apparently eliminates duodenal their absorption of fats and of fat-soluble vi¬
stump leak and reduces the incidence of tamins; but the clinical status of patients so
dumping, but cannot be carried out in all treated has remained unchanged at least as
cases. In an impressive series of 1,600 cases long as five years after operation.17 Esopha¬
compiled over 18 years, Scott et al11 noted geal reflux, a common finding after vagoto¬
recurrent ulcération in only 13 patients my, is usually asymptomatic.18 The impres¬
(0.8%). In eight of the 13, a second opera¬ sion that vagotomy decreases the volume
tion was performed and the vagotomy was and enzyme concentration of pancreatic se¬
found to be incomplete; three of these eight cretion has not been universally confirmed.
patients had the Zollinger-Ellison syn¬ Vagotomy abolishes the pancreatic secretory
drome. Results of the partial gastrectomy response to gastric distention, and the en¬
were held to be satisfactory in 94% of the zyme response to insulin hypoglycemia, but
total series. In an effort to reduce the mor¬ does not alter the response to secretin.19
tality (2.3%), the lesser procedure of vagot¬
omy and pyloroplasty was substituted in the Aids to Selection of Procedure
treatment of elderly debilitated patients.
Vagotomy.—As shown by a series of stud¬ In attempts to determine the common de¬
ies by Dragstedt and his co-workers,12·13 nominators in successful surgical treatment
vagotomy reduces acid secretion by three of peptic ulcer, and to provide reliable bases
means: abolition of the cephalic phase, de¬ for the choice of procedure in the individual
creased response of gastric glands to humor¬ case, hydrochloric acid production has been
al stimulants such as gastrin and histamine, measured by a variety of techniques in¬
and reduction of paristaltic activity and its cluding the 12-hour overnight secretion test,
stimulation of secretion. Because reduction the histamine stimulation test, and others.
of peristalsis renders the stomach atonic and The basal night secretion is presumed to in¬
delays emptying, the undesirable complica¬ dicate the amount of vagai activity; the re¬
tion of gastric stasis must be eliminated by a sponse to histamine provides a quantitative
complementary drainage procedure. reflection of parietal cell function. Welch20

Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/13/2015

 pointed out that several patterns arise from
these studies, and that each suggests the ap¬
propriate operative procedure.
Basal Histamine
Secretion Response Surgical Procedure
High High Vagotomy and subtotal
gastrectomy
High Low Vagotomy and
pyloroplasty
Vagotomy and
gastroenterostomy
Low High Subtotal gastrectomy
In the great majority of ulcer patients, the
acid-peptic juice level is in the moderately
elevated range. Very few are "hypersecre-
tors" (1,500 cc overnight, 100 mEq free hy¬
drochloric acid, or 4 mEq hydrochloric
acid/hr basal secretion) suggestive of the
Zollinger-Ellison ulcerogenic pancreatic tu¬
mor. When a patient of this category can be
"cured," it is only by total gastrectomy or
removal of the pancreatic tumor or
which are often malignant, or by both.
In certain instances, the primary indica¬
tion for surgical intervention may point to
the procedure of choice, as when pyloroplas¬
ty provides direct visualization of the bleed¬
ing duodenal ulcer, permitting suture liga¬
tion; or when gastroenterostomy is selected
for the scarred, obstructed, "burned-out,"
chronic duodenal ulcer. In the case of perfo¬
ration of a duodenal ulcer, many elect only
to close the perforation.21 In one third of
reported patients so treated, there have been
no sequelae; however, since symptoms recur
in the remainder of these cases, and an addi¬
tional surgical procedure is required in one
half of patients with recurrent symptoms,
some surgeons22·23 have carried out definitive
procedures, such as vagotomy with pyloro¬
plasty, which have not been complicated by
mediastinitis; while others24·25 have per¬
formed resection with good results.
Present Study
Method.—The hospital and clinic charts of
664 patients with peptic ulcer disease treated
surgically at this hospital during the decade
1955 through 1964 were reviewed and the fol¬
lowing questionnaire was addressed to all.
Since your operation for ulcer:
1. Have you had any recurrence of your old
ulcer pain?
2. Have you gained weight?
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/13/2015
Have you lost weight?
3. Have you had any episodes of vomiting
blood or passing black stools?
4. Have you had any vomiting?
5. Do you restrict your diet because of fear
of ulcer pain? If so, how?
6. Do you smoke? How much?
7. Have you had persistent diarrhea?
8. Does your stomach fill up easily after
you have eaten only a little?
9. Do you have excessive belching?
10. Do you feel faint after eating?
11. Do you break out in sweats after eating?
12. Do you have nausea after eating, and
have to lie down to get relief?
13. How do you feel about your operation?
Do you think it did you any good?
Many patients were called by telephone for
additional information. A large number are
seen frequently for other problems, by mem¬
bers of the medical staff, so that a continuous
check on the patient's condition is available.
Follow-up of at least one year and reply to the
tumors, questionnaire were obtained from 527 (78.5%)
of the patients. Those lost to follow-up included
some who had died from related or unrelated
causes, and others who could not be located.
Results.—The sex ratio of the respondents
(Table 1)—approximately 2:1 male:female—
contrasts with the usually reported 4:1 or 5:1
preponderance of males. A valid reason for
this divergence is not readily apparent; but
51% of the local members of the Kaiser
Foundation Health Plan who are between
20 and 64 years of age are women and the
male:female ratio of general surgical patients
in this hospital during the decade surveyed
was 1:1. Occupational stress added to home
tensions may have accounted for increased
incidence of peptic ulcération in women;
Table 1.—Distribution by Sex and Age of
527 Patients Surgically Treated for Peptic Ulcer
Patients
No. %
Sex
Male 358 68
Female 169 32
Ap.e Group, yr
?0-?0 14 2.7
30-29 89 16.9
40-49 188' 35.7
r.0-59 149 28.2
60-69 78 14.8
70-79 9 1.7
 Table 2.—Distribution of 527 Cases of tial vagotomy can quantitatively reduce the
Peptic Ulcer by Site of Ulcération acid levels sufficiently to permit the ulcer to
Site Patients heal.
No. %
Duodenal Ulcer.—Our results from all
types of surgical procedures used for duo¬
Duodenum 423 80.2 denal ulcer, the largest number of cases, are
Stomach 62 11.8
Combined 23 4.4 grouped according to the chief preoperative
Marginal 19 3.6 difficulty in Table 4. The indications for in¬
tervention are shown in Table 5.
The fair and poor results of treatment are
many of our female patients work under analyzed in relation to the surgical proce¬
trying conditions as supermarket checkers, dure in Table 6.
waitresses, or in factories. Dumping.—The 5.7% incidence of dump¬
The distribution by site of ulcération is ing after vagotomy with pyloroplasty for du¬
shown in Table 2. odenal ulcer compares favorably with
Our over-all evaluation of results of oper¬ figures in the literature. This complication
ation is summarized in Table 3. The criteria occurs with destruction of the pyloric sphinc¬
for this assessment were as follows: Where ter mechanism by either resection or pylo¬
the answers to all items on the question- roplasty. The recently published conclusion
narie were favorable and the clinic chart con¬ of Bowers and Stockard,28 that dumping oc¬
firmed the subjective evaluation, the result curs less often after pyloroplasty than after
was rated "good." If there were persistent gastric resection, but slightly more often
minor complaints of discomfort, mild dump¬ than after gastroenterostomy, confirms that
ing, occasional diarrhea or vomiting, the the intact pyloric sphincter plays an impor¬
result was considered "fair." Severe pain, tant role in this problem. In the experience
recurrent bleeding, persistent diarrhea, fre¬ of Bowers and Stockard, the incidence of
quent dumping, or recurrent ulcération were dumping was not altered by associated va¬
criteria of a "poor" result. gotomy, but was increased from zero in pa¬
All factors responsible for the therapeutic tients with ulcer alone to 6.9% in those with
failures could not be identified. Some of the associated hiatal hernia.
more frequent coexisting conditions were Diarrhea.—Diarrhea of significant degree
alcoholism with or without cirrhosis, chronic has been reported to follow vagotomy with
pulmonary emphysema, heavy smoking, or without gastrectomy in from 12% to 68%
psychoneurosis, and arteriosclerotic corona¬ of cases, the latter percentage having been
ry disease. The Hollander test, used in 16 cited by Harkins et al29 as one reason for
patients with "poor" operative results, indi¬ favoring selective gastric vagotomy. Its
cated in nine instances (56%) that vagoto¬ cause is unproved, but according to Snap¬
my was incomplete. Approximately the per30 it may represent a malabsorption syn¬
same percentages of incomplete vagotomy in drome resulting from pancreatitis, often
the "unsatisfactory" groups were reported present in these patients. Other suggested
by Bürge and Clark20 and by Weinberg.27 explanations include proliferation of foul
It has been stated that a single minute vagai colonie flora in a stomach that is not empty¬
branch, if left intact, may activate the entire ing properly, and survival of diarrhea-pro¬
gastric secretory mechanism; but Drag¬ ducing organisms in an environment charac¬
stedt15 has recently contended that even par- terized by lower gastric acidity. Bowers and
Stockard28 attributed the
Table 3.—Results of All Operations for diarrhea to the pyloroplasty
Peptic Ulcer, All Sites, in 527 Patients rather than the vagotomy.
Good Fair Poor Deaths Totals They observed it most often
in patients with associated
Elective 227 (61%) 63 (18%) 67 (19%) 5 (1.4%) 357 (68%)
hiatal hernia (20.7%); its
Emergency 96 (56%) 34 (20%) 40 (24%) 15 (8.8%) 170 (32%)
incidence was 14.3% in
Totals 323 (61%) 97 (18%) 107 (21%) 20 (3.8%) 527 (100%) those with ulcer alone. The
diarrhea has been said to be

Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/13/2015

 Table 4.—Results Correlated With Principle Preoperative Problem
in 423 Cases of Duodenal Ulcer
Good Fair Poor Total

Hemorrhage
'Vagotomy and pyloroplasty 76 (69.7%) 15 (13.8%) 18 (16.5%) 109
Billroth II 11 2 6 19
Vagotomy, and gastroenterostomy 5 0 2 7
Vagotomy and Billroth II 5 4 1 10
Vagotomy and Billroth I 10 0 1
Billroth I _J_ 1 _J_ _3
^_99 (66.4%)_22 (14.8%)_28 (18.8%)_149
Intractability
Vagotomy and pyloroplasty 76(62.3%) 27(22.1%) 19(15.6%) 122
Billroth II 7 0 0 7
Vagotomy and gastroenterostomy 0 0 1 1
Vagotomy and Billroth II 2 0 1 3
Vagotomy and Billroth I 0 10 1
Billroth I
_1_ _0 _0_ _1
_86
Perforation
(63.7%)_28 (20.7%)_21(15.6%)_135
Closure, vagotomy, and pyloroplasty 10(71.4%) 4(28.6%) 0 14
Closure and pyloroplasty 114 6
Closure 18 (36.7%) 13 (26.6%) 18 (36.7%) 49
Vagotomy and Billroth I _J_ 0 0 1
_30 (42.9%)_18 (25.7%)_22 (31.4%)_70
Obstruction
Vagotomy and pyloroplasty 36 (72.0%) 9 (18.0%) 5 (10.0%) 50
Billroth II, 2 2 0 4
Vagotomy and gastroenterostomy 10 1 1 12
Vagotomy and Billroth II 0 0 1 1
Billroth I
_2_ _0_ 0 2
50(72.5%) 12(17.4%) 7(10.1%) 69

Table 5.—Indications for Surgical Intervention recurrent bleeding, will be mentioned with
¡n 423 Patients With Duodenal Ulcer
relation to the series as a whole.
Patients Vomiting.—Twenty-three patients suf¬
fered intermittent, protracted vomiting as
•

No.
Hemorrhage 149
Intractability 135
Perforation 70
Obstruction 69
often severe, resistant to therapy, and serious¬
ly debilitating. This has not been our experi¬
ence. In the 5% of our patients who had this
complication after vagotomy and pyloroplas¬
ty for duodenal ulcer, it was nearly always
medically manageable; and many welcomed
the tendency to softer stools as a happy
change from their former constipation.
Pain, Bleeding.—Forty-two, or almost
half of the 97 patients in whom the results of
vagotomy with pyloroplasty for duodenal
ulcer were classified by us as "fair" to
"poor," complained of pain. Bleeding re¬
curred in only 2% of patients se treated.
The difficulties inherent in the objective as¬
sessment of pain, and our management of
%
late as six weeks after surgical treatment for
35.3 duodenal ulcer. Nine of the 16 patients in
31.9
16.5 whom this complication followed vagotomy
16.3 and pyloroplasty required additional surgi¬
cal intervention because of "pyloric obstruc¬
tion." (This term does not accurately de¬
scribe the underlying problem, but merely
indicates the failure of food to pass through
the pylorus.) The interesting finding at op¬
eration in four of these cases was a widely
patent pyloroplasty. The clinical picture of
obstruction in these instances, with retention
of barium in the stomach as long as six hours,
must therefore be due to profound atony fol¬
lowing vagotomy. In the other five cases, the
symptoms were accounted for by significant
pyloric narrowing: after the standard two-
layer closure in four cases; and in the re¬
maining one, after application of the one-
layer method described by Weinberg.8
The fact that most of the instances of re¬
tention occurred after operations performed

Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/13/2015

 Table 6.—Analysis of Fair and Poor Results of Selected Surgical Procedures for
Duodenal Ulcer in 156 of 423 Patients in Whom These Procedures Were Used
Dumping Diarrhea Pain Bleeding Vomiting Recurrence

Vagotomy and pyloroplasty 97/295 17(5.7%) 15(5.3%) 42 (14.9%) 6(2.1%) 16(5.4%) 16(5.4%)
Billroth II TÜ73D 2 (6.7%) 6 (20%) 1 (3.3%) 1 (3.3%) 4 (13.3%)
Vagotomy and gastroenterostomy 5/20 1 (5%) 1 (5%T 2 (10%) ( 1 (5%) 2 (10%)
Vagotomy and Billroth II "7714 2 (14%) TU%) 4 (28%) 2 (14%) 2 (14%)
Vagotomy and Billroth I l/3~ 0 1 (33%) 0
Closure perforation 31/49 17(34.7%) 5(10.2%) 4(8.2%) 15(30.6%)
Closure and pyloroplasty "576" 3 (50%) 1 (16.7%) 1 (16.7%) 1 (16.7%)

Table 7.- -Analysis of Postoperative Deaths in 11 (2.6%)

of 423 Patients With Duodenal Ulcer
Procedure Age, Sex

Vagotomy and pyloroplasty 4/281(1.4%) 71, M Bleeding duodenal ulcer Myocardial infarct,
hemorrhage, subacute
bacterial endocarditis,
sepsis_
78, M Bleeding duodenal ulcer Pulmonary complications
63, M Bleeding duodenal ulcer Cardiac .irrest
69, M Pyloric obstruction Pulmonary embolus
Billroth II 2/30 (6%) 53, M Intractable pain Leaking duodenal stump
49, M Hemorrhage Leaking duodenal stump
Vagotomy and gastroenterostomy 1/20 (5%) 56, F Pyloric obstruction Cardiac arrest
Vagotomy and Billroth II 1/14(11%) 59, M Intractable pain, Common bile duct injury,
hemorrhage bile peritonitis, sepsis
Vagotomy and Billroth I 0/3
Closure of perforation 2/49 (4%) 61, M iCïïrrhotîc Peritonitis, aspiration
pneumonia, delirium tremens
62, F Steroid ulcer Sepsis, peritonitis
Closure and pyloroplasty 1/6 (16%) 58, M Stress Ulcer Pulmonary embolus

by one member of the staff Table 8.—Relationship of Type of

would suggest that some pe¬ Surgical Procedure to Results in
423 Cases of Duodenal Ulcer
culiarity of technique is per¬ Results
haps the causative factor.
Another member of the staff,
Good Fair Poor Totals
who has twice encountered
cardiospasm after vagotomy Vagotomy and pyloroplasty 198(66%) 55(19%) 42(15%) 295
and pyloroplasty, has at¬ Billroth I 20 (67%) 4 (13%) 6 (20%) 30
and
tributed this complication to Vagotomy
gastroenterostomy 15(75%) 1 (5%) 4 (20%) 20
his mobilization of the distal Closure of perforation 18 (37%) 13 (26%) 18 (37%) 49
Uther- 29
esophagus through a small
incision anterior to the hia-
tus, as a means of gaining
several centimeters proximally on the vagai Table 9.—Results of Vagotomy and Pyloroplasty
trunks. Both instances of cardiospasm were Related to Primary Problem In
295 Patients With Duodenal Ulcer
completely relieved by the passage of an
esophagoscope. Results
The importance of postoperative gastric
Good Fair
decompression, preferably through a tube Primary Problem Poor Totals

gastrostomy, is well-recognized, and all of Hemorrhage 76(70%) 15(14%) 18(16%) 109

these patients received nothing orally for at Intractability 76(62%) 27(22%) 19(16%) 122
least five days before suction was discontin¬ Obstruction 36 (72%) 9 (18%) 5 (10%) 50
Perforation 10(70%) 4(30%) 0 14
ued and feedings were begun.

Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/13/2015

 Recurrence.—While the Table 10.—Relations Between Indications for Operation, Type of
overall rate of recurrence of Surgical Procedure, and Results in 62 Patients With Gastric Ulcer
radiographically document¬ Results
ed ulcer in patients treated Indication Total Good Fair Poor Deaths
by any surgical procedure
for duodenal ulcer was Intractability
Billroth I 21 14 4 3 0
9.4% (40 of 423 patients), Billroth II 11 4 1 6 3
the recurrencerate after Vagotomy and pyloroplasty 2 2 0 0 0

vagotomy and pyloroplas¬ Vagotomy and Billroth I 10 0 10

Pyloroplasty 2 0 2 0 0
ty for duodenal ulcer was Pyloroplasty and wedge
5.4% (16 of 295 patients). resection 2 0 1 11
All of 18 patients having 39 20 8 11 4

"poor" results from simple (62.9%)_

Hemorrhage
closure of perforated duode¬ Billroth I 3 3 0 0 0
nal ulcer required addition¬ Billroth II 3 2 0 11
al surgical correction. This Vagotomy and pyloroplasty 2 2 0 0 0
Pyloroplasty 2 10 10
represents 37% of the group Vagotomy and Billroth II 110 0 0
—a figure somewhat higher Vagotomy and wedge
resection 10 1 0 0
than the 33% often quoted.
12 9 1 2 1
None of the 14 patients (19.4%)
in whom definitive vagot¬ Perforation
Closure 9 3 2 4 2
omy and pyloroplasty were Billroth i
performed for perforation _2_ _2_ _0_ 0 0
11 5 2 4 2
had poor results. (17.7%)
Deaths.—On the basis of Totals 62 34 11 17 7
(100%) (54.8%) (17.8%) (27.4%) (11.3°
a ten-year study King'sat
County Hospital, Brooklyn,
NY, Enquist et al·'11 concluded that the death the over-all percentage of good results in
rates for massive gastroduodenal hemor¬ Table 4 (61%) is noted to be less than the
rhage from peptic ulcer are the same wheth¬ average of these four figures (69%). This
er treatment is surgical or nonsurgical. After arrangement reemphasizes that the poorest
the age of 50 years, the mortality for this results from surgical treatment for peptic
complication increases sharply with each ulcer are obtained in patients with intrac¬
decade. It will be noted in Table 7 that four table lesions.
of the five patients with massive bleeding Gastric Ulcer.—As diagnostic measures
from duodenal ulcer were 59 years or older. have improved during the last decade, elim¬
The three deaths that followed gastric resec¬ inating concern that cancer may be over¬
tion resulted from technical problems inher¬ looked, the trend has been away from gastric
ent in this operation. Cardiac complica¬ resection for gastric ulcer. Nevertheless, the
tions occurred coincidentally in three cases; disturbing recurrence rate (30% within five
pulmonary embolism, in two. years) of benign gastric ulcers treated medi¬
When the results of operation are consid¬ cally indicates that more should be treated
ered in relation to the type of procedure (Ta¬ surgically. Knowing that distal gastrectomy
ble 8), it is seen that the only group of sta¬ (Kelling-Madlener operation) would cure a
tistically meaningful size is that comprising high gastric ulcer, the surgeons of our staff
patients treated by vagotomy and pyloroplas¬ employed simple drainage procedures and,
ty. If this group, in turn, is subdivided ac¬ like Farris and Smith,32 noted equally good
cording to the indication for intervention results from the lesser operation (Table 10).
(Table 9) and arranged in descending order Wedge specimens may be taken for biopsy at
of frequency of good result: the same time, to rule out malignancy, but
as Bartlett33 pointed out, the probability of
Obstruction 72%
Perforation 71% survival for patients with benign-appearing
Hemorrhage 70% ulcers is the same whether treatment is medi¬
Intractability 62% cal or surgical.

Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/13/2015

 The four deaths after Table 11.—Relation Between Indications for Operation,
Billroth II procedures for Type ef Surgical Procedure, and Results in 23 Patients
With Combined Duodenal Ulcer and Gastric Ulcer
gastric ulcers (Table 10)
were due to (1) blown-out Results
duodenal stump, (2) bleed¬ Good Deaths
Indication Total Fair Poor
ing and peritonitis, (3) sep¬
Intractability
sis, gram-negative organism Vagotomy and Billroth I 7
(urinary tract infection), Vagotomy and pyloroplasty 1
and (4) pulmonary embo¬ Billroth I 1
Pyloroplasty 1
lus. The death following To"
pyloroplasty with wedge re¬ (43.5%)
section was due to shock, Perforation
pneumonia, and cardiac fail¬ Closure 4
The two deaths after Vagotomy and pyloroplasty 1
ure.
Vagotomy and Billroth I 1
closure of perforation were ^6~
attributed to peritonitis and (26.1%)
pneumonia. The "poor" re¬ Hemorrhage
sults in three patients after Suture and pyloroplasty 1 1*
the Billroth I procedure Vagotomy and pyloroplasty 1 0
Vagotomy and Billroth I 1 0
were manifested by persist¬ Billroth II 2
A1'
ent pain, dumping, and em¬ 2
esis requiring reoperation. (21.7%)
Combined Gastric and Obstruction
Vagotomy and Billroth I 1
Duodenal Ulcer.—The com¬ Billroth I 1
bined gastric and duodenal 2
ulcers in 23 patients (Ta¬ (8.7%)
ble 11) were presumably Totals 23 8 5 10
traceable to pyloric spasm (100%) (34.8%) (21.7%) (43.5' i) (8.7%)
and antral stimulation. All *
Pulmonary embolus, hemorrhage, sepsis, hepatic coma 60 days after
operation.
of the four patients of this t Leaking duodenal stump, peritonitis.
group in whom perforation
was treated
by simple clo¬
sure subsequently required
Table 12.—Indications, Surgical Procedure, and Results in
vagotomy and pyloroplasty, 19 Patients With Marginal or Stornai Ulcer (No Deaths)
which produced "good" re¬
sults in two, "fair" in one, Results
and "poor" in one. Pain was
Total Good Fair Poor
a complaint after six opera¬
Indication
tions; diarrhea was trouble¬
Hemorrhage 12
some after three. Roentgen-
(63.2%)
ographically demonstrated Intractability 5
ulcer recurred in one pa¬ (26.3%)
Obstruction 2
tient after a Billroth I pro¬
(10.5%)
cedure for intractability. Procedure
Marginal or Stornai Ulcer. Vagotomy
—Nineteen patients with Transthoracic 2 2
marginal (or stornai) ulcer Abdominal 2 2
were treated surgically dur¬ Vagotomy and pyloroplasty 4 4
Vagotomy and Billroth II 2 2
ing the period under study. Vagotomy and gastroenterostomy 1 0
The indications and the re¬ Billroth I 3 2
Billroth II 3 2
lationships between surgical Revision of gastroenterostomy 1 1
procedure and results are Suture ligation _1_ 1
shown in Table 12. Totals 19
Emergency Cases.—Sev- (100%) (84.2%) (5.3%) (10.5%)

Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/13/2015

 eral important points be¬ Table 13.—Results of All Types of Emergency Operative
come apparent when all op¬ Procedure Performed for Any Indication in 170 Patients
With Peptic Ulcer at Any Site (32% of Series)
erations performed on an
Additional
emergency basis for ulcer in No. Good Fair Poor Surgery Deaths
any site are separated from Hemorrhage 78/l~78 (43%)
the elective procedures (Ta¬ Vagotomy and pyloroplasty 54 38 12 4 4 3
ble 13). Billroth II 12 9 12 0 3
1. The mortality in the Vagotomy and
gastroenterostomy 2 2 0 0 0 0
emergency group was 8.8% Vagotomy and Billroth II 110 0 0 0
—
15 deaths in 170 cases, Vagotomy and Billroth I 110 0 0 0
Billroth I 2 10 10 0
compared to 1.4% in the Suture of bleeding vessel 6 2 0 4 3 1
elective group (5 of 357). 78 54 13 11 7 7
Among patients treated with Perforation 87(100%)
vagotomy and pyloroplasty, Closure 62 2116 25 19 6
Closure and pyloroplasty 6 114 1
there were four deaths in 4
Closure, vagotomy, and
the emergency group (5.5%) pyloroplasty 15 11 4 0 0 0
and none in the 222 elective Vagotomy and Billroth I 2 2 0 0 0 0
Billroth I 2 2 0 0 0 0
cases.
87 37 27 29 23 7
2. Thelong-term results
of e'mergency intervention Obstruction 5/69 (74%)
Vagotomy and pyloroplasty 4 4 0 0 0 1
for hemorrhage are surpris¬ _J_
Billroth II _1 __0 _0 _0 0
ingly better than those of _5 5 0
0_0_
elective surgery for this Totals 170 96 34 40 30 15
complication. _(56%) (20%) (24%) (18%) (8.8%)
and
3. Simple closure of per¬ Emergency vagotomy
pyloroplasty only 73 53 16 4 0 4
forated chronic duodenal ul- (25%) (72%) (22%) (5.5%) (5.5%)
cers is unsatisfactory treat¬
ment—63% in the study had fair to poor intervention 24 hours or more after the onset
results and 37% required additional surgical of bleeding. These comments apply to recur¬
procedures (Table 4). rent hemorrhage requiring two to four pints
of blood and six to eight hours to stabilize,
Comment not to recurrences characterized only by
Many aspects of a retrospective study transient melena or minimal bleeding that
such as this leave much to be desired. Some required no replacement of blood.
patients are lost to observation after opera¬ The early use of upper gastrointestinal
tion. In a number of individuals with sub¬ x-ray series in bleeders has helped us to
jective complaints there was no objective determine the presence or absence of ulcer,
evidence of recurrence; some in whom all and of esophageal varices. Screening tests
follow-up studies have yielded normal results such as the partial thromboplastin time and
continue to have pain. One must either take prothrombin time have helped to differenti¬
these complaints "with a grain of salt" or ate ulcer bleeding from that due to blood
consider the results of operation to be "fair" dyscrasia.
or "poor." In some other cases there were One criterion for operation for "intractable
several indications for surgical intervention, ulcer" was continuous pain while the pa¬
eg, pain and bleeding. Operation for massive tient was under strict medical management
recurrent hemorrhage was performed much for at least one year, or a recurrence of major
earlier in patients with a history of bleeding pain after management for several years.
and intractability than in those without such Prompted by the disturbingly high inci¬
a history. We intervened surgically after a dence of poor results from simple closure of
six- to eight-hour period of observation, dur¬ perforated chronic duodenal ulcer, and en¬
ing which blood and fluid replacement ther¬ couraged by the success reported by others
apy was vigorously applied. The results from to follow definitive operations for this con¬
such early operation for recurrent bleeding dition, we employed vagotomy and pyloro¬
were found to be far better than those from plasty in 14 of the patients with perforation

Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/13/2015

 in this series. The results were gratifying. If
one excludes those with no history of ulcer
prior to onset of the perforation, and confines
the procedure to those with chronic ulcer, at
least one third will be spared the problems
potentially related to the operation, since it
is well documented that simple closure suf¬
fices in acute ulcers.34
Some of the accepted indications for a
definitive operation in perforated ulcera are34:
(1) associated hemorrhage or obstruction;
(2) long history of ulcer which has been dif¬
ficult to control medically; (3) previous per¬
foration; and (4) perforation occurring while
the patient is following a well-planned medi¬
cal regimen.
As presented here, our results may appear
poor in comparison with those reported by
others. Ih many articles, however, the results
of surgical treatment for peptic ulcer have
been considered in only two categories, "sat¬
isfactory" or "recurrent"; thus,
Satisfactory (%) Recurrent (%)
Holt and
Lithgoess 91.4 1.5
Beattiese 90.6 0.6
Weinberg8 89.5 5
Bürge and
Clark20 87 5.6
If the "good" and "fair" results in our se¬
ries are
combined, 79% of the total of 527
patients, and 84% of the 295 with duodenal
ulcer treated by vagotomy and pyloroplasty
would be considered to have had a "satisfac¬
tory" outcome. The addition of complicated
cases and other operations has diluted our
"good" results to a deceptively low figure.
Nobles'37 recent report of long-term fol¬
low-up after vagotomy and gastroenterosto¬
my would suggest that the incidence of re¬
currence rises startingly after ten years
(23%) and 15 years (28%); so that perhaps
observation periods shorter than ten years
do not yield reliable data. Among 76 of his
patients with duodenal ulcer studied by the
Hollander test before and after primary va¬
gotomy with posterior gastroenterostomy,
the vagotomy was shown to be incomplete in
eight (10%). Ulcer recurred in none of
these eight patients. Of the remaining 68 pa¬
tients, half had insulin-fast achlorhydria,
and half showed a small amount of free acid
but a flat acid curve. In each of these two
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/13/2015
groups of 34 patients, about 25% experi¬
enced recurrence; but the recurrences ap¬
peared to take place, on an average, a few
years later than after posterior gastroen¬
terostomy alone. Welch and Rodkey3·20
found the same trend after resection, with
0.5% recurrence in the first year, 1% in the
second year, and a gradual rise to 8% six
years after operation. At five years after
Billroth II procedure, Thompson and Stew¬
art38 reported 4.5% to 8% recurrence. At
ten years, Kiefer39 found anastomotic ulcer
after gastrectomy alone in 13% of patients.
According to Newton and Judd,40 the ad¬
vantages accruing from restoration of gastro¬
duodenal continuity by the Billroth I oper¬
ation were nullified by ulcer recurrence
rates as high at 15% at the end of six years
—a problem that can be eliminated by the
addition of vagotomy to this procedure.
Among 374 patients treated surgically for
duodenal ulcer, Colcock and Farha41 noted
"satisfactory" results in 90%, and recur¬
rence and death rates for various procedures
as follows:
Recurrence (%) Death (%)
Vagotomy and
pyloroplasty 5-13 1
Subtotal
gastrectomy 4 2-3
Vagotomy and
hemigastrectomy 1 2-3
They concluded that for the majority of pa¬
tients, subtotal gastrectomy is the most sat¬
isfactory procedure; but that for thin per¬
sons and for the preponderant number of
women, vagotomy with hemigastrectomy is
the procedure of choice. Both Amendola30
and Welch and Rodkey3 found vagotomy
combined with limited gastrectomy and a
Billroth I reconstruction, when technically
feasible, the best elective procedure for duo¬
denal ulcer.
Pyloroplasty with suture of the ulcer and
vagotomy is replacing gastrectomy as the
emergency treatment for massive upper-gas¬
trointestinal tract bleeding from benign gas¬
tric or duodenal ulcer. Foster et al42 recent¬
ly reported that 30% of 96 patients had died
after gastrectomy, while 13% of 102 patients
died after vagotomy and pyloroplasty.
Welch and Rodkey3 noted that 6% of
 younger patients and 30% of older patients Table 14.—Comparison of Case Material in
died after resection for bleeding. Ulcération Three Peptic Ulcer Series
or bleeding recurred in 15% to 24% of pa¬ Scott Evans Silberman
et al11 et al34 and Winkley
tients that survived simple partial gastrecto- ·
Total cases 1,600 564 527
for acute massive hemorrhage, observed % % %
by Leape and Welch.43 It is interesting to Elective operation 98
2
71
29
compare the case material in our series with Emergency operation —

those in recent reports from the groups
headed by Scott and by Evans34 (Table
14).
There can be little doubt that the reason
for intervention and the timing of the proce¬
dure have a significant influence on the re¬
sults, regardless of the operative technique
employed. Mortality figures for emergency
cases may be four to ten times greater than
in elective cases.
Conclusions
The welter of statistics compiled by various
surgeons and institutions is evidence that
there is no one operation for peptic ulcer dis¬
ease. The data are made almost meaningless
by variations in patient selection and tech¬
niques and by difficulties inherent in the
evaluation of results. As demonstrated by the
studies of Weinberg,8 27 Herrington, Edwards,
and their colleagues,1·11'44 and others, one
must take into account the social, economic,
and physical status of the patients studied.
Results in groups consisting primarily of in¬
digent, elderly patients are poorer than those
reported from private institutions or Veterans
Administration hospitals.
Categorizing the results of a particular
surgical procedure as "good," "fair," or
"poor" on the basis of persistent symptoms
or recurrence is not simple. Previous opera¬
tion, and such coexistent conditions as pul¬
monary emphysema, cirrhosis, pancreatitis,
arteriosclerosis, psychoneurosis, and alco¬
holism make evaluation difficult. Incomplete
vagotomy or an inadequate drainage proce¬
dure may partly explain unsatisfactory re¬
sults, but the intangible human factors for
which no unerring yardstick has been in¬
vented must also be assessed.
As a result of frequent critical evaluations
in our institution, our surgical treatment of
peptic ulcer has gradually shifted to the al¬
most exclusive use of vagotomy with pyloro¬
plasty. In the great majority of our patients,
this operation has proved safe and satisfac¬
tory, and has produced few complications.
Intractability 53
—
56 36
Hemorrhage 30 17 32
Obstruction 13 24 14
Perforation 4 2 18
In view of the additional hazards and
difficulties introduced by supplementary re¬
section, we do not feel that extension of the
margin of safety by this means is warranted
in most cases.
Summary
Among 527 retrospectively analyzed oper¬
peptic ulcer, vagotomy with pyloro¬
ations for
plasty was performed 295 times for duo¬
denal ulcer, the most frequent indications
being hemorrhage (35.6%) and intractabil¬
ity (31%). The incidence of recurrence was
5%; of mortality, 1%. The four deaths oc¬
curred in patients undergoing emergency
surgery; no deaths occurred in the 222 elec¬
tive cases.
The poor results following simple closure
of perforated chronic duodenal ulcers lends
strong support to the use of definitive vagot¬
omy and pyloroplasty in these cases. In 14
patients so managed there were no compli¬
cations and no poor results.
In qur opinion, vagotomy with pyloroplas¬
ty is the procedure of choice for the vast ma¬
jority of patients with peptic ulcer.
References
1. Edwards, L.W., et al: Surgical Treatment of
Duodenal Ulcer by Vagotomy and Antral Resection,
Amer J Surg 105:352-360, 1963.
2. Brookes, V.S.; Waterhouse, J.A.H.; and Thorn,
P.A.: Partial Gastrectomy for Peptic Ulcer, Gut
1:149-162, 1960.
3. Welch, C.E., and Rodkey, G.V.: Partial Gas-
trectomy for Duodenal Ulcer, Amer J Surg 105:338\x=req-\
346, 1963.
4. Harvey, H.D.: Twenty-four Years Experience
With Elective Gastric Resection for Duodenal Ul-
cer, Surg Gynec Obstet 112:203-210, 1961.
5. Griffith, C.A., and Harkins, H.N.: Selective
Gastric Vagotomy: Physiologic Basis and Tech-
nique, Surg Clin N Amer 42:1431-1441 (No. 6) 1962.

Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/13/2015

 6. Wheeler, H.B.; Hoar, C.S., Jr.; and Curtis,
L.E.: Measured Subtotal Gastrectomy for Duodenal
Ulcer, Arch Surg 92:52-57 (Jan) 1966.
7. Kay, A.W., and Cox, A.G.: "Recent Advances
in Relation to Surgery of the Stomach," in Irvine,
W.T. (ed.): Modern Trends in Surgery, Washing-
ton, DC: Butterworth, 1962, pp 1-7.
8. Weinberg, J.A.: Vagotomy and Pyloroplasty in
the Treatment of Duodenal Ulcer, Amer J Surg
105:347-351, 1963.
9. Fry, W.J., and Thompson, N.W.: Vagotomy
and Pyloroplasty for Duodenal Ulcer, Surg Clin N
Amer 46:359-365 (No. 6) 1966.
10. Colcock, B.P.: The Operation of Choice for Du-
odenal Ulcer, Surg Clin N Amer 44:653-657 (No. 3)
1964.
11. Scott, H.W., Jr., et al: Vagotomy and Antrec-
tomy in Surgical Treatment of Duodenal Ulcer Dis-
ease, Surg Clin N Amer 46:349-358 (No. 2) 1966.
12. Dragstedt, L.R., and Owens, F.M., Jr.: Supra-
diaphragmatic Section of Vagus Nerves in Treat-
ment of Duodenal Ulcer, Proc Soc Exp Biol Med
53:152-154, 1943.
13. Oberhelman, H.A., Jr., and Dragstedt, L.R.:
Effect of Vagotomy on Gastric Secretory Response
to Histamine, Proc Soc Exp Biol Med 67:336-339,
1948.
14. Nielsen, J.R.: Development of Cholelithiasis
Following Vagotomy, Surgery 56:909-911, 1964.
15. Dragstedt, L.R.: Vagotomy in the Surgical
Treatment of Peptic Ulcer, Surg Clin N Amer
46:1153-1162 (No. 5) 1966.
16. Wastell, C., and Ellis, H.: Faecal Fat Excre-
tion and Stool Colour After Vagotomy and Pyloro-
plasty, Brit Med J 1:1194-1197, 1966.
17. Cox, A.G., et al: Aspects of Nutrition After
Vagotomy and Gastrojejunostomy, Brit Med J
1:465-469, 1964.
18. Clark, S.D.; Penry, J.B.; and Ward, P.: Oeso-
phageal Reflux After Abdominal Vagotomy, Lancet
2:824-826, 1965.
19. Dreiling, D.A.; Druckerman, L.J.; and Hol-
lander, F.: Effect of Complete Vagisection and Vagal
Stimulation on Pancreatic Secretion in Man, Gas-
troenterology 20:578-586, 1952.
20. Welch, C.E.: "Subtotal Gastrectomy" for Duo-
denal Ulcer, Surg Clin N Amer 46:339-348 (No. 2)
1966.
21. Byrd, B.F., Jr., and Carlson, R.I.: Simple Clo-
sure of Peptic Ulcer: A Review of End Results, Ann
Surg 143:708-713, 1956.
22. Farris, J.M., and Smith, G.K.: Vagotomy and
Pyloroplasty: A Solution to the Management of
Bleeding Duodenal Ulcer, Ann Surg 152:416-429,
1960.
23. Pierandozzi, J.S.; Hinshaw, D.B.; and Rogers,
F.: Vagotomy and Pyloroplasty for Acute Perforat-
ed Duodenal Ulcer, West J Surg 65:139-142, 1957.
24. Jordan, G.L.; DeBakey, M.E.; and Cooley,
D.A.: The Role of Resective Therapy in Manage-
ment of Acute Gastroduodenal Perforation, Amer J
Surg 105:396-400, 1963.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/13/2015
25. Moore, H.G., Jr.; Harkins, H.N.; and Meren-
dino, K.A.: The Treatment of Perforated Peptic Ul-
cer by Primary Gastric Resection, Int Abstr Surg
98:105-123, 1954.
26. Burge, H., and Clark, P.A.: The Ten Year Re-
sults of Vagotomy in Chronic Duodenal Ulcer, Gas-
troenterology 39:572-573, 1960.
27. Weinberg, J.A.: "Pyloroplasty and Vagotomy
for Duodenal Ulcer," in Current Problems in Sur-
gery, Chicago: Year Book Medical Publishers, Inc.,
1964, 1-36.
28. Bowers, R.F., and Stockard, C.G., Jr.: Dump-
ing Syndrome Following Pyloroplasty, Arch Surg
92:39-43 (Jan) 1966.
29. Harkins, J.N., et al: Selective Gastric Vagoto-
my, Ann Surg 158:448-460, 1963.
30. Amendola, F.H.: The Choice of Operation for
Duodenal Ulcer, Amer J Gastroent 44:118-128, 1965.
31. Enquist, I.F., et al: Statistically Valid Ten\x=req-\
Year Comparative Evaluation of Three Methods of
Management of Massive Gastroduodenal Hemor-
rhage, Ann Surg 162:550-560, 1965.
32. Farris, J.M., and Smith, G.K.: Role of Pyloro-
plasty in Surgical Treatment of Gastric Ulcer, suppl,
Ann Surg 154:293-297, (No. 6) 1961.
33. Barlett, M.K.: The Surgical Treatment for
Gastric Ulcer, Surg Clin N Amer 46:319-327 (No. 2)
1966.
34. Evans, R.H.; Zajtchuk, R.; and Menguy, R.:
Role of Vagotomy and Gastric Drainage in the Sur-
gical Treatment of Duodenal Ulcer, Surg Clin N
Amer 47:141-146 (No. 1) 1967.
35. Holt, R.L., and Lythgoe, J.P.: Treatment of
Chronic Duodenal Ulcer by Vagotomy and Anterior
Pylorectomy, Brit J Surg 52:27-32, 1965.
36. Beattie, A.D.: Vagotomy and Partial Pylorec-
tomy: A New Procedure for Duodenal Ulcer, Lancet
1:525-530, 1950.
37. Nobles, E.R., Jr.: Vagotomy and Gastroenter-
ostomy: 15-Year Follow-Up of 175 Patients, Amer
Surg 32:177-182, 1966.
38. Thompson, J.E., and Stewart, C.F.: Gastrecto-
my for Peptic Ulcer, Ann Surg 139:721-730, 1954.
39. Kiefer, E.D.: Life With a Subtotal Gastrecto-
my: A Follow Up Study Ten or More Years After
Operation, Gastroenterology 37:434-438, 1959.
40. Newton, S.E., III, and Judd, E.S.: Long Term
Follow-Up Proves Billroth I Gastric Resection In-
adequate for Permanent Control of Duodenal Ulcer,
Surg Gynec Obstet 116:170-174, 1963.
41. Colcock, B.P., and Farha, G.J.: Choice of Oper-
ation for Duodenal Ulcer, Postgrad Med J 37:130\x=req-
137, 1965.
42. Foster, J.H.; Hall, A.D.; and Dunphy, J.E.:
Surgical Management of Bleeding Ulcers, Surg Clin
N Amer 46:387-396 (Nov 2) 1966.
43. Leape, L.L., and Welch, C.E.: Late Prognosis
of Patients With Upper Gastrointestinal Hemor-
rhage, Amer J Surg 107:297-305, 1964.
44. Herrington, J.L., et al: Vagotomy and Antral
Resection in the Treatment of Duodenal Ulcer, Ann
Surg 150:499-516, 1959.