A Thousand Operations for Ulcer Disease

A retrospective study of 1068 patients who had operations for peptic ulcer disease in the 12-year period from January 1,1974, to January 1, 1986, permits these conclusions: (1) The number of patients admitted to the Massachusetts General Hospital (MGH) has declined steadily in the years of this study–1974–1986. The average number of patients admitted with a diagnosis of peptic ulcer disease in precimetidine years–1974, 1975, and 1976–and in recent years–1982, 1983, and 1984–shows a decline of 39.3% in admissions. In the same periods, the average number of operations per year has declined from 92 in precimetidine years to an average of 71 (16.5%) recently. The decline has been greatest in patients operated on electively for duodenal ulcer. Operations for massive hemorrhage and acute perforations and the number of deaths have remained nearly constant. (2) The overall mortality rate was 10.3%. The mortality following elective operations for pain was 0.5%; for urgent operations, including those for obstruction, 4.5%, and for bleeding other than massive, 7.5%; and for emergency operations, including those for acute perforation, 20.9%, and for massive hemorrhage, 22.1%. The main causes of death were organ failure (most commonly of the lungs) and sepsis. (3) Early complications were documented 345 times and were followed by reoperation in 84 cases, or 7.4% of the total. (4) Delayed stomal function was noted in 63 cases and required reoperation in 14. It was most common after Roux anastomoses and required operative intervention most commonly after gastric resection, Billroth I (GRBI). Delay was three times as common when vagotomy (V) was added to GR. (5) Early postoperative hemorrhage was a serious complication when it occurred after operations for acute perforations or massive hemorrhage. The incidence was 3.7% after suture of a perforation; after operations for acute massive hemorrhage, it was 4.3% after pyloroplasty and vagotomy, with or without arterial ligation [PV(L)], and 0.3% after GR, with or without arterial ligation [GR(L)]. (6) Late complications led to reoperation in 66 cases (6.2%). The most important were recurrent ulceration and alkaline gastritis. (7) Recurrence rates after a minimum follow-up of 5 years (based on survivors of initial procedures and a second operation, both in the MGH) were 20.5% after suture of a perforation, 6.2% after PV, 2.3% after GRBII, and 0.4% after GRVBII. These figures are lower than expected; incomplete follow-up and improved medical care are factors. (8) The favored elective operation for duodenal, gastric, and anastomotic ulcer disease in this hospital in the past 12 years has been GRV, chiefly because of the low recurrence rate and the wide dispersal of patients. (9) Acute perforations in good risk patients preferably are treated by GR, with or without V[GR(V)], regardless of age, provided that operative conditions are favorable. Bad risks, unless the perforation is too large to close other than by resection, or if it is associated with hemorrhage, a posterior ulcer, or obstruction, usually are treated by suture or closure with an omental patch. (10) Patients with acute massive hemorrhage preferably are treated by GR(V), regardless of age, provided that operating conditions arc satisfactory. When the ulcer is in the duodenum, even though control of bleeding is not as effective by PVL as with GR(V), unsatisfactory operating conditions will make PVL preferable. (11) Catheter duodenostomy, used in 10.5% of GRBII operations, essentially has eliminated problems with the duodenal stump. (12) The treatment of alkaline gastritis by Roux anastomoses has been satisfactory in about half of the cases in which it has been used. It is suggested that gastric motility problems have been placed in this same category and should be isolated as a syndrome; total gastrectomy may be helpful in some of these cases.