DOUGLAS AND DUTHIE: GASTRIC AND DUODENAL ULCER 72 1

VAGOTOMY FOR GASTRIC ULCER COMBINED WITH DUODENAL ULCER

BY M. C. DOUGLAS AND H. L. DUTHIE UNIVERSITY DEPARTMBNT OF SURGERY, ROYAL INFIRMARY, SHEFFIELD

SUMMARY Many of the favourable reports on the conservative

treatment of gastric ulcers do not clearly define what proportion of the cases had associated duodenal disease. During the past 6 years we have treated 39 patients with gastric ulcers combined with duodenal ulcer or scarring by vagotomy and pyloroplasty. Over the same period 44 cases with gastric ulcer have been similarly treated.

At an average follow-up of just under 3 years the functional results were good for 83 per cent, satis- factory for 14 per cent, and poor for 3 per cent for combined ulcers, compared with 54 per cent, 25 per cent, and 21 per cent respectively for gastric ulcers. These differences are just statistically significant. Thus, vagotomy with pyloroplasty has been shown to give better results when used in the treatment of combined ulcers than when solitary gastric ulcers are treated by this operation.

DUODENAL ulcer disease is found to coexist with about one-quarter of all gastric ulcers treated surgically in this country (Tanner, 1954; Johflson, 1956; Orr, 1962). There is a growing belief, strongly advocated by Johnson (1964)~ that these com- bined ulcers are best considered separately from ulcers of the body of the stomach alone. This idea is based on observations that, compared with ulcers confined to the body of the stomach, combined ulcers occur at a younger age, show a greater male preponderance, have a higher gastric acid secretion, and manifest an increased frequency in patients with blood group 0 (Tanner, 1954; Billington, 1958; Johnson, 1965; Jepson, Johnston, and Duthie, 1971). Thus, in these several ways they more closely re- semble duodenal ulcers and there is widespread acceptance of the advice that surgical treatment in combined ulcer disease should be directed towards the duodenal ulcer. Although based on reasonable argument there is scant evidence to support this practice. Patients with combined ulcers have been found to do well after both Polya and Billroth types of gastric resection (Tanner, 1954; Hickenbotham, 1956; Walters, 1957), and vagotomy and drainage have only recently been evaluated (Wasunna, Kennedy, Gillespie, and Kay, 1971). In a recent controlled trial Duthie, Moore,

Bardsley, and Clark (1970) found that the results after vagotomy and pyloroplasty for gastric ulcer were inferior to those reported by others (Burge, 1966; Farris and Smith, 1966; Kraft, Fry, and Ransom, 1966). They speculated that the inclusion of patients with combined ulcers and prepyloric ulcers (about one-third of all gastric ulcers) would favourably influence the overall result-given the reasonable expectation that these two latter groups

would behave like duodenal ulcers after vagotomy and pyloroplasty. In this report patients with combined gastric and

duodenal ulcers treated by vagotomy and pyloro- plasty are compared with patients having ulcers confined to the body of the stomach treated in the same fashion over the same period. The functional result is assessed in both groups.

h5ATERIALS AND MTHODS During the 6 years beginning in October, 1964,

617 patients had elective operations for all types of peptic ulcer in the Department of Surgery, Sheffield.

Table Z.-MODIFIED VISICK CLASSIFICATION OF SYMPTOMS Grade I : No gastric symptoms Grade z : Mild symptoms easily controlled by simple care such

Grade 3a: Moderate symptoms not controlled by simple care

Grade 3b: Moderate symptoms interfering with social or econo-

Grade 4: Symptoms as bad or worse than preoperatively, or

as small meals and avoiding certain foods

but not interfering with social or economic life

mic life

recurrent nlcer

Table ZI.-DETAILS OF THE GROUPS UNDER STUDY

I I

FATE OP PATIENTS I C~~O.D I GASTRIC ULCER

No. having vagotomy and pyloroplasty Operative deaths Late unrelated deaths It Late gastric carcinoma§ Lost to follow-up Less than 6 months’ follow-up Number interviewed

~ ~

* A 76-year-old man died of bronchopneumonia. t Both men died of heart disease z and 3 years after operation. $ Male, died of meningitis 8 months after operation. 0 See Discussion for details.

Forty-nine were diagnosed at operation as having gastric ulcer combined with duodenal ulcer or duodenal scar and 104 had gastric ulcers alone. This study is based on the 39 patients with combined ulcers and the 44 with gastric ulcers who underwent vagotomy and pyloroplasty. Prepyloric ulcers were not included in the gastric ulcer group. The bulk of these latter patients also formed part of a controlled trial on the surgical treatment of gastric ulcers (Duthie and others, 1970).

Seven patients in each group had selective vago- tomy while the remainder had truncal vagotomy. Heineke-Mikulicz pyloroplasty was used in all cases. The ulcer was biopsied in 32 of the combined and 38 of the gastric ulcers. Thirteen were not biopsied early in the period: 10 because they were healed and 3 because they were thought to be obviously benign. Later a circumferential biopsy was performed on all

722 BRIT. J. SURG., 1971, Vol. 58, NO. 10, OCTOBER

TYPE OF ULCER

- - Combined ulcers (39 patients)

ulcers regardless of appearance. An insulin test meal (Hollander, 1946) was performed in 20 of the com- bined and 16 of the gastric ulcer patients. This was negative by Hollander’s criteria in 19 and 13 re- spectively in the first postoperative week.

INCIDENCE POST- DURATION

OPERATION COMPLI- STAY IN FOLLOW- (years) CATIONS* HOSPITAL up

(per cent) (days) (months)

AGE AT OF OPERATIVE OP

35‘9

7-66) (range,

51.3

Table III.-CLINICAL DETAILS : THE SIMILARITY OF THE GROUPS STUDIED

I I I I

Combined ulcers (35 patients)

Gastric ulcers (37 patients)

9 25.7 8 22.9 18 51’4

22 59’5 5 13.5 10 27’0

Gastric ulcers I 51.1 1 18.0 1 11.2 1 ’ 31.2

6-63) (44 patients) (range,

No PAST HISTORY OF BLJi6DING

No. of Patients Per cent

TYPE OF ULCER

~

* Includes wound infection, burst abdomen, deep-vein thrombosis, pulmonary embolus, and bronchopneumonia.

Table ZV.-CLINICAL DETAILS: THE DIFFERENCES BETWEEN THE GROUPS STUDIED

O m OR MORE EPISODES OF BLIEDING

No. of Patients Per cent TYPE OF ULCER

Combined ulcers (39 patients)

Gastric ulcers (44 patients)

5 Student’s 2-test, P<o.o5. Pentagastrin stimulation, 6 pg. per kg.

During the follow-up study the available patients were interviewed by the authors. An assessment of the functional result was made in each case according to a modified Visick (1948) classification (Table I ) . The patients were weighed and their haemoglobin concentration was estimated. Symptoms suggestive of recurrent ulcer were investigated by a barium- meal examination, gastroscopy, and insulin test meal.

RESULTS The fate of the patients who underwent vagotomy

and pyloroplasty is shown in Table ZZ. The 3 patients who presented with gastric carcinoma some years after vagotomy will be discussed in detail later. Thus, 35 combined and 39 gastric ulcer patients were interviewed. Data from the case notes of the other 9 patients were used only for preoperative and operative assessment.

Incidence.-Thirty-two per cent of the 153 patients operated on with gastric ulcer were found to have coexisting duodenal ulceration or scarring. Conversely, 9.6 per cent of all the duodenal ulcers were associated with a gastric ulcer. The overall incidence of combined ulcers was 7.9 per cent of 617 patients with all types of peptic ulcer.

Preoperative and Operative Assessment.- The age at operation, the postoperative morbidity, the duration of stay in hospital after surgery, and the length of follow-up were similar in both the

MALE DURATION

R ~ ~ ~ ~ * (months 1

OF F ~ ; ~ P ~ ~ ~ SYMPTOMS?

S.E.M.)

156.1 1 18.7 4 3 : I

1.7 : I 79’5 16.5

combined and gastric ulcer groups (Table 111). Certain differences can nevertheless be demonstrated. The male preponderance was greater in the con- comitant ulcer group as was the duration of symptoms before surgery. This latter fact was also shown by the

Table V.-INCIDENCE OF PREOPERATIVE VOMITING

NONE OCCASIONAL FREQUENT

ULCER 1 No. of I Per I No. of I gt I No. of I Per Patients cent Patients Patients cent

T Y P E OF

I I

Combined ulcers I 34 I 87.1 I 5 I 12’9 .. (39 patients)

(44 patients) Gastric ulcers I 27 I 65’9 I 14 1 34‘1

Comparison between the two xa = 3’9110, d.f. I, P < O . O g .

groups showed a significant difference :

Table VZZ.-ACTIVITY OF THE CONCOMITANT LJLceRS AT OPERATION

I I

Duodenum Stomach

The data were obtained from the operation notes of 37 of the 39 patients with concomitant ulcers. A comparison between the activity of the two ulcer sites revealed a significant difference: x s = 7’4617. d.f. I, P<o.oI .

younger age at which symptoms first occurred. The pentagastrin-stimulated peak acid output (P.A.O.) was also greater in the concomitant ulcer patients (Table IV). Although generally the symptomatology was indistinguishable, vomiting was significantly more common and severe in the concomitant ulcer group (Table V). Five patients in this group had presented with pyloric stenosis. On the other hand, preoperative haematemesis or melaena was signi- ficantly more common in the gastric ulcer group (Table VZ). Two patients in each group had a history of previous perforation.

Thirty-seven of the combined ulcer patients were sufficiently well documented to assess the activity of the ulcers at operation. Although the duodenal ulcer was healed in about half of the patients the gastric ulcer was nearly always active and this difference is statistically significant (Table VIZ).

Postoperative Assessment.-According to the Visick classification, patients with combined ulcers

DOUGLAS AND DUTHIE: GASTRIC AND DUODENAL ULCER

I 2 3a

4 3b

Total

723

13 37'1 I3 33'3 16 45'7 8 20 5 5 14'3 10 25-6 0 2 5'1 I 2 8 6 15'4 - ~ ~ -

35 39

fared significantly better than those with gastric ulcers after vagotomy and pyloroplasty (Table VZZI). A similar result was noted when grades I and 2 were considered to be good results, grade 3a just satis- factory, and grades 3b and 4 failures.

Table VZZZ.-COMPARISON OF RESULTS ACCORDING TO THE VISICK CLASSIFICATION

I COMBINED ULCERS I GASTRIC ULCER GRADE I patients No. of I Per cent I/ E$Gfs Per cent

Good (grades I, 2) 82.9 21 534 Satisfactory (grade 3a) Poor (grades 3h, 4)

A comparison between individual grades showed a significant difference: x2 = 9.7169, d.f. 4, P<o.of . When grades I and 2 are combined (good) as well as grades 3b and 4 (poor), x2 = 8.1989, d.f. 2, P i o ~ o 2 .

Table IX.-ANALYSIS OF POOR RESULTS Derails No. of Cases

Combined Ulcers Multiple symptoms: vomiting, diarrhoea, I

and dumping

Gastric Ulcers

- Total I

Recurrent ulcer proved 5 Haemorrhage leading to gastrectomy I

Persistent diarrhoea 2 3 weeks after vagotomy

Total S

Table X.-EPISODES OF DIARRHOEA*

I NONE 1 ONCE TYPE OF PER WEEK PER WEEK

Combined 25 71'4 8 22'9 2 5'7 ulcers (35 patients)

(39 patients) Gastric ulcers 1 21 1 53'8 I 12 1 30.8 1 6 1 15.4

I I I I I I

Diarrhoea was defined as 3 or more loose stools per day. Com- parison between the two groups showed no significant difference.

There are 5 proved recurrent ulcers in the gastric ulcer group and none in the combined ulcer group. Although not by itself significant (P<o.1>0.05) it accounts to a large extent for the differences between the two groups. Further details of the poor results are shown in Table IX .

Fifty-nine per cent of the combined ulcer patients and 50 per cent of the gastric ulcer patients had an increased frequency of their bowel actions, but in only I and 3 patients respectively was this normally more than three per day. Episodic diarrhoea was also more frequent in the gastric ulcer group but not significantly so (Table X ) .

The incidence of fullness after normal meals (17 per cent), vomiting (6 per cent), postprandial colic

(8 per cent), and vasomotor symptoms (20 per cent) was about the same in each group. Similarly the mean and distribution of body-weight (expressed as a percentage of ideal weight) and haemoglobin concentration were similar in both groups, allowing for the greater proportion of females in the gastric ulcer group.

DISCUSSION The incidence of combined ulcers in this series is

higher than in some other reports, even allowing for bias due to the surgical material. This is probably a reflection of the diligence with which the duodenum was examined at operation because of the need to select cases with care for gastric ulcer trial (Duthie and others, 1970). The previously well-established differences between concomitant and solitary gastric ulcers were again brought out in th is study. The male to female ratio for combined ulcers approached the 5.6 : I seen in the 464 duodenal ulcers which were treated over the same period. The younger age of onset was also closer to that for duodenal ulcer. The pentagastrin-stimulated peak acid output was slightly lower than the 45.3 mEq./l. for duodenal ulcers seen in the same hospital (Jepson and others, 1971). The observation that the gastric ulcer was active while the duodenal ulcer was often healed has also been made before (Johnson, 1965; Welsh, Floyd, McKeon, Moore, and Cohn, 1965). Together with the pre- viously mentioned kinship to duodenal ulcers this is in accord with the view that the gastric ulcer is secondary to the duodenal pathology in combined ulcer disease.

The high incidence of vomiting in the combined ulcer group could possibly indicate gastric retention. This would be in agreement with Johnson (1956)~ and Dragstedt (1969, who found delayed gastric emptying in a very high proportion of their patients with concomitant ulcers. However, apart from 5 cases of pyloric stenosis, there is no evidence that the vomiting was due to hold-up, and Mangold (1958) and Welsh and others (1965) found that few patients with combined ulcer had gastric retention. Thus, the significance of the vomiting remains one of con- jecture. Gross haemorrhage was much more common in the gastric ulcer group. This is at variance with the observations of Johnson (1956)~ Mangold (1958), and Welsh and others (1969, although similar to that of Aagaard (1964). The explanation may lie, in part, in our selection of patients for this series. Although patients undergoing emergency surgery for haemorrhage were excluded, those having semi- elective surgery on a routine list, during the same hospital admission for haematemesis and melaena, were not so excluded. If indeed combined ulcers bleed more vigorously than gastric ulcers then a larger number would have had emergency operations and would thus be outside our selection criteria.

The main aim of this study was to document the effectiveness of vagotomy and pyloroplasty in the treatment of combined ulcers. The functional result of 83 per cent good, 14 per cent satisfactory, and only 3 per cent poor more than justifies the use of this form of treatment. The results are comparable to those reported after gastric resection for combined ulcer (Walters, 1957). They are better than some reports of duodenal ulcers treated by vagotomy and

724 BRIT. J. SURG., 1971, Vol. 58, NO. 10, OCTOBER

pyloroplasty (Cox, Spencer, and Tinker, 1969). When compared with patients with gastric ulcers also treated by vagotomy and pyloroplasty, the patients with combined gastric and duodenal ulcera- tion fared significantly better. Although no ulcers recurred in the group with combined ulcers, and 13 per cent recurred in the group with gastric ulcer, the difference was not significant. This lack of recurrence of combined ulcers was also a feature after treatment by gastric resection (Tanner, 1954 j Hickenbotham, 1956; Walters, 1957). On the other hand, the incidence of recurrent gastric ulcers in our study is greater than the experience of some others (Burge, 1966; Farris and Smith, 1966; Kraft and others, 1966). The reason is not clear. Incomplete vagotomy was not a major factor, all 5 patients having a negative response to insulin by Hollander's criteria. Nor was gastric stasis important as only I patient had slightly delayed emptying on barium- meal examination.

Of particular interest are the 3 patients not in the follow-up study who presented with gastric carcinoma several years after vagotomy and pyloroplasty. One was a woman who was 37 years old when she pre- sented with combined duodenal and gastric ulcers 5.5 years before undergoing gastrectomy for carci- noma. The gastric ulcer was not biopsied because of the current view that when two ulcers coexist the gastric one is rarely malignant. The other 2 patients were male and were both 47 years old when they had had a vagotomy and pyloroplasty for gastric ulcers 2.5 and 5 years before presenting with cancer. Both had a four-quadrant biopsy at the original operation and even in retrospect there was no evidence of malig- nancy. In I the ulcer was observed to have healed on postoperative barium-meal examination. The general consensus of opinion holds that there is only a slender causal relationship, if any, between benign gastric ulcer and carcinoma (Robbins, 1959). An incidental carcinoma may have developed in these 3 cases, This is thought by some to occur more frequently after benign gastric ulcerative disease (Helsingen and Hillestad, 1956). Alternatively, the ulcers may have always been malignant. The 2 men with gastric ulcers had had symptoms for a total of 7.5 and 10 years before presenting with cancer. However, no one knows the time required for the genesis of gastric cancer even when evolving from carcinoma in-situ, and Mallory (1940) pointed out that a superficial carcinoma could undergo peptic ulceration and this may hold in check the remaining cells in the periphery. As these cells may be scattered they could be missed unless a total biopsy was done. The fact that one ulcer was seen to heal on barium- meal examination does not exclude malignancy, although only 10 comparable cases have been reported (Bachrach, 1962). When active ulceration of the stomach and duodenum present simultaneously the lesion in the stomach is said to be invariably benign (Pack and Banner, 1967). However, the simultaneous presentation of an active duodenal ulcer and Iinitis plastica has been reported (Ryan and Beal, 1957). It is also well documented that a healed duodenal ulcer may be complicated by a carcinoma (Fischer, Clagett, and MacDonald, 1947; Lampert, Waugh, and Dockerty, 1950). On these grounds it would seem unwise to regard a coexisting duodenal

ulcer as a guarantee of benignity in a gastric ulcer. As the prognosis for small ulcerating cancers of the stomach following gastric resection is much better than for other types of gastric cancer (Nyhus, 1962) great care must be taken to ensure that a malignant ulcer is not missed.

Vagotomy and pyloroplasty have been shown to be an effective cure for patients with combined ulcers since none has recurred after a mean follow-up of 3 years. The functional result i s good and is in keeping with the generally held view that combined ulcers behave more like duodenal ulcers than gastric ulcers. This is supported by the significantly poorer functional result, including a 13 per cent recurrence rate, seen in ulcers of the body of the stomach which were similarly treated. I t also emphasizes the warning introduced by the findings of Duthie (1970) against extrapolating the results of the treatment of combined ulcers to the management of all gastric ulcers. The importance of adequately classifying gastric ulcers in reporting the result of therapy is also brought out by these results.

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