Highly selective vagotomy 5-15 years on.

Highly selective vagotomy for duodenal ulcer was performed on 307 patients between 1973 and 1983 without operative mortality. Of these, 283 (92.2 per cent) were followed up prospectively for a minimum of 5 years. Recurrent ulcer was diagnosed in 49 (17.3 per cent). The recurrent ulcer rate increased from 13.2 per cent at 5 years to 19.4 per cent at 12 years. Age, length of history, previous haemorrhage or perforation and preoperative acid output were not associated with increased risk of recurrent ulceration. The risk in men and smokers was higher but not significantly so. The recurrence rate for individual surgeons varied from 5.3 to 25.6 per cent. Failure of healing with H2-receptor antagonists was not associated with a higher recurrent ulcer rate. Patients with a strong family history (more than one first degree relative affected) had a significantly higher recurrence rate (33.2 per cent at 10 years) than those without (13.5 per cent at 10 years). Of the 49 recurrent ulcer patients, 30 (61.2 per cent) required either an operation or regular H2-receptor antagonists. Of the 250 patients (81.4 per cent) available in 1988 for review of symptoms 5-15 years after operation, 5.4 per cent had dumping, 8.9 per cent epigastric pain, and 11.8 per cent heartburn every day or most days. H2-receptor antagonists were required by 10.7 per cent of patients on a frequent or regular basis. Of 239 patients who answered the question, 218 (91.2 per cent) felt that their symptoms had been cured or greatly improved and 203 (84.9) considered the operation a success. Despite the high recurrence rate, the operation was successful in controlling ulcer symptoms in around 90 per cent of patients and produced postvagotomy symptoms--none severe--in around 5 per cent of patients.

Mucosal proctectomy and colo-anal anastomosis for distal ulcerative proctocolitis.

Four patients with long-standing symptomatic ulcerative colitis confined to the left colon and rectum were treated by resection, mucosal proctectomy and colo-anal sleeve anastomosis. There was no operative mortality or anastomotic leakage. Follow-up has ranged from 12 to 66 months (mean 52 months). Loose bowel motions with urgency and frequency of defaecation were troublesome postoperative symptoms. Recurrence of the colitis in the neorectum with extension into the proximal colon occurred in all patients within 3 to 11 months (mean 6 months) of operation. This necessitated total proctocolectomy with ileostomy in three patients (mean 18 months postoperatively). In the fourth patient the recurrence is medically controlled without a stoma more than 5 years after operation. This operation is unsuitable for the treatment of segmental ulcerative proctocolitis.

Late results of mucosal proctectomy and colo-anal sleeve anastomosis for chronic irradiation rectal injury.

Ten patients with severe chronic irradiation injury to the rectum were treated by mucosal proctectomy and colo-anal sleeve anastomosis. The indications were: recurrent rectal bleeding (five), stricture (three), fistula (one) and intractable pain (one). Overall follow-up has ranged from 8 to 77 months (mean 40 months). In the present survivors (n = 7) the follow-up ranges from 18 to 77 months (mean 52 months). Six patients have been followed up for more than 3 years and four for more than 5 years. There was no operative mortality. Three anastomotic strictures occurred but the protecting stoma could be closed in all but one patient. Continence was acceptable although urgency and frequency of defaecation were troublesome symptoms. The operation is recommended for life-threatening, haemorrhagic chronic irradiation injury to the rectum.

Resectable colonic carcinoma--a five year experience.

Clinical characteristics, mode of presentation and pathological features of resectable carcinoma of the colon have been studied in 224 cases presenting between January 1971 and December 1975. Minimum length of follow-up is five years and is complete. Forty-three per cent of patients survived five years or more, only 23 per cent of tumours being early in histological terms. The conventional high risk groups contributed little to the total and their active surveillance will not significantly improve the overall statistics.

Surgical aspects of intestinal injury due to pelvic radiotherapy.

Seventy-one patients with intestinal injury secondary to pelvic irradiation had predominantly large bowel lesions. Seventeen cases were treated conservatively and 54 came to surgery, 28 patients having more than one operation. Following this essentially salvage surgery there were more ileal than colonic anastomotic leaks. Thirty-four patients died during the follow-up period (2-12 years), 19 from recurrent malignancy, and nine as a result of continuing radiation effects. Seventy per cent of the patients who had a radiation fistula died as a result of malignancy. Of 42000 cases of pelvic malignancy treated by irradiation over the decade 1972-1982, surgical referrals for complications constituted 1.7%, with an overall radiation-related mortality of 0.2%. It is our opinion that colostomy alone has little part to play in this condition, and a policy based on excisional surgery is suggested.

Late mortality after surgery for peptic ulcer.

To examine the claim that life expectancy is reduced after curative peptic-ulcer surgery, we studied mortality and its causes in 779 men with peptic ulcer treated surgically between 1947 and 1965. The minimum follow-up period of survivors was 15 years. There was an excess mortality in the three major age groups (30 to 39, 40 to 49, and 50 to 59 years at operation), as compared with the general population (P less than 0.001), with a mean shift of 9.1 years in the survival curve. Surgery was not the direct cause of death. In particular, the eight deaths from carcinoma of the stomach were no more than expected. Excess mortality was due to smoking-associated disease, which accounted for 200 deaths. Eighty-three per cent of the patients were cigarette smokers. We conclude that substituting highly selective vagotomy for gastrectomy will not lead to improved survival, because 80 per cent of patients now having operations for ulcer are heavy cigarette smokers.

Cholelithiasis following peptic ulcer surgery: a prospective controlled study.

An association between gastric surgery and gallstones has been suggested but conflicting conclusions are found in the literature. A prospective study of 118 patients with proved duodenal ulcer disease has been undertaken to determine the true incidence of gallbladder disease. Sixty-one patients undergoing surgery and 57 patients treated medically were matched for age, sex and weight. All patients had oral cholecystography at entry into the study and at 18 months and 109 were reviewed radiologically at 3 years. Three patients in the surgical group developed asymptomatic gallstones whereas none were detected in the medical group. This gives an incidence of gallstones of 4.9 per cent 3 years after gastric surgery. These findings are discussed.

A questionnaire for assessment of the result of peptic ulcer surgery.

Details of a 22-item questionnaire used to assess the result of surgery for peptic ulcer are given. Tested in 47 patients the questionnaire correlates well with the Visick grading. The 100-mm line test and post-operative alkali consumption are less accurate measures of outcome. As an alternative to the Follow-Up Clinic, as a potential predictor of result, and as an indicator of the quality of life, the questionnaire has much to offer.

Malignant lymphoma and extensive viral wart formation in a patient with intestinal lymphangiectasia and lymphocyte depletion.

A patient is described, the subject of a previous report (Ross et al., 1971), who subsequently developed gross peripheral mosaic warts and a malignant small bowel lymphoma in association with marked lymphocyte depletion.