Truncal vagotomy and pyloroplasty for non-complicated duodenal ulcer: results 22-26 years after surgery.

OBJECTIVE: To assess the long-term results of truncal vagotomy and pyloroplasty in patients with non-complicated duodenal ulcer. PATIENTS AND METHODS: Between 1969 and 1973, 210 patients underwent surgery for non-complicated duodenal ulcer. Of these, 92 were followed up for 22-26 years. In 67 the assessment was conducted at the outpatient consultation and in 25, by phone. RESULTS: In 57% of patients the results were good or very good. Postpandrial fullness, heartburn and diarrhea were reported by 59, 52 and 42% of patients, respectively. Ulcerative recurrence affected 18% of patients. Although the relapsing rate was smaller in women as compared to men (7% versus 20%), physical condition and quality of life after surgery in the latter group were much worse. Thirty-five patients (38%) underwent reoperation. The distribution of patients according to the modified Visick classification after all the reoperations was as follows: I = 22 patients; II = 30 patients; III = 23 patients and IV = 17 patients. CONCLUSION: Long-term results after surgery for duodenal ulcer were not very encouraging, so we suggest for these patients a medical treatment and just in exceptional cases of refractory ulcers we would recommend a surgical procedure with minimal long-term complications.

Vagotomía troncular y piloroplastia en el tratamiento de la úlcera duodenal no complicada: resultados a los 22-26 años de la cirugía / Truncal vagotomy and pyloroplasty for non-complica ted duodenal ulcer: results at 22-26 years after surgery

Objetivo: valorar los resultados a largo plazo (22-26 años) de la vagotomía troncular y piloroplastia en el tratamiento electivo de la úlcera duodenal no complicada. Pacientes y métodos: entre los años 1969-1973, se intervinieron quirúrgicamente 210 pacientes por úlcera duodenal no complicada, de los cuales en 92 pudo realizarse una valoración de resultados a largo plazo. En 67 la valoración se realizó en consultas externas y en 25 por teléfono. Resultados: en el 57 por ciento de los pacientes los resultados fueron buenos o muy buenos. La pesadez postprandial, la pirosis y la diarrea fueron síntomas que afectaron respectivamente al 59, 52 y 42 por ciento de los pacientes. La recidiva ulcerosa fue del 18 por ciento. A pesar de que la recidiva en las mujeres fue inferior a la de los hombres (7 vs 20 por ciento), el estado físico y la calidad de vida de las primeras fue mucho menos satisfactorio que la de los segundos después de la cirugía. Las reintervenciones después de la cirugía por ulcus fueron en número de 35, involucrando al 38 por ciento de los pacientes. Los resultados de los pacientes utilizando la clasificación de Visick modificada, después de todas las reintervenciones, fue como sigue: I= 22; II=30; III=23 y IV= 17.Conclusiones: los resultados a largo plazo de la cirugía electiva de la úlcera duodenal no complicada no han sido muy alentadores, por lo que sugerimos para el control de esta enfermedad el tratamiento médico y sólo excepcionalmente en la úlceras refractarias un tratamiento quirúrgico que minimice las complicaciones a largo plazo (AU)

Factors related to the failure of endoscopic injection therapy for bleeding gastric ulcer.

BACKGROUND: Although endoscopic injection therapy is effective in controlling initial haemorrhage from peptic ulcer, between 10% to 30% of patients suffer rebleeding. AIM: To assess the factors that may predict the failure of endoscopic injection in patients bleeding from high risk gastric ulcer. SUBJECTS: One hundred and seventy eight patients admitted for a gastric ulcer with a bleeding or a non-bleeding visible vessel were included. METHODS: Patients received endoscopic therapy by injection for adrenaline and polidocanol. Twelve clinical and endoscopic variables were entered into a multivariate logistic regression model to ascertain their significance as predictive factor of therapeutic failure. RESULTS: Eighty seven per cent (155 of 178) of patients had no further bleeding after endoscopic therapy. Endoscopic injection failed in 23 (13%) patients: 20 (12%) continued to bleed or rebleed, and three (1%) patients could not be treated because of inaccessibility of the lesion. Logistic regression analysis showed that therapeutic failure was significantly related to: (1) the presence of hypovolaemic shock (p = 0.09, OR 2.38, 95% CI: 0.86, 6.56), (2) the presence of active bleeding at endoscopy (p = 0.02, OR 2.98, 95% CI: 1.12, 7.91), (3) ulcer location high on the lesser curvature (p = 0.04, OR 2.79, 95% CI: 1.01, 7.69), and (4) ulcer size larger than 2 cm (p = 0.01, OR 3.64, 95% CI: 1.34, 9.89). CONCLUSION: These variables may enable identification of those patients bleeding from gastric ulcer who would not benefit from injection therapy.

Evaluation of duodenogastric reflux in gallstone disease before and after simple cholecystectomy.

Duodenogastric reflux (DGR) has been suggested as an etiopathogenic factor in gastric disease in patients with gallstones. We evaluated the DGR levels in 15 patients before and after simple cholecystectomy for gallstones and compared the results with those of 15 healthy subjects. Gastric juice was obtained by continuous nasogastric suction for 24 hours. The bile acids (BA) present in the samples were quantified by thin-layer chromatography and in situ spectrofluorometry. The mean BA concentration for the control subjects was 2.25 mumol reflux/hour, whereas the mean value for the 15 patients with cholelithiasis was 8.86 mumol reflux/hour before cholecystectomy and 24.55 mumol reflux/hour after cholecystectomy. Five patients did not have detectable BA in the gastric juice in both analyses; the remaining 10 patients showed a significant increase in the BA after surgery. From these data, we conclude that gallstone disease is not always accompanied by an increased DGR. However, in patients in whom DGR is present, its level is higher than in control subjects and increases significantly after cholecystectomy. This is probably due to the greater amount of bile in the duodenum that may reflux through an incompetent pyloric channel.

Bile reflux in postoperative alkaline reflux gastritis.

This study evaluates enterogastric reflux (EGR) levels in patients with and without symptoms of postoperative alkaline reflux gastritis (PARG) after gastric surgery. The bile acids (BA) present in the gastric juice were quantified by thin-layer chromatography and spectrofluorometry. The mean BA concentration for controls was 2.25 mumol reflux/hour, for 15 asymptomatic patients 47.94 and for 15 patients with symptoms of PARG 125.79. After biliary diversion by a Roux-en-Y anastomosis in the latter, their BA in 13 of these patients after surgery, and relapsed in only one during a 4-year follow-up. The remaining two patients had the lowest preoperative BA levels in this group. These results indicate that EGR is increased after gastric surgery more markedly indicated that EGR is increased after gastric surgery more markedly in patients with symptoms of PARG, and that patients who have high levels of EGR (more than 80 mumol BA reflux/hour) clearly benefit from biliary diversion.