Recurrent ulceration after highly selective vagotomy for duodenal ulcer

Recurrent peptic ulceration was diagnosed in 9 per cent of 433 patients who were treated by elective highly selective vagotomy (HSV) for duodenal ulcer (DU) between 1969 and 1980. In 233 patients followed up for 5-12 years (12 per cent being lost to follow-up), the incidence of recurrence was 10.7 per cent. The site of recurrence was duodenal in 23 patients, pyloric in 4, gastric in 6 and combined duodenal and gastric in 2 (total of 35 patients). One patient presented with a perforation, l4 with haemorrhage and 30 with epigastric pain. Asymptomatic patients were not endoscoped and so asymptomatic recurrence would have been missed. Nine patients were treated by reoperation (5 Polya partial gastrectomy, 4 vagotomy + antrectomy), the remainder with cimetidine. There was no mortality. When the 35 patients with recurrence were compared with the patients without recurrence, no preoperative factors could be identified that might be used to predict recurrence. Thus, for the two groups, the sex distribution, age, length of ulcer history, previous ulcer complications and preoperative acid outputs (basal and maximal) were very similar. This was true also when the data for patients with true recurrence in the duodenum were examined separately. Hence, contrary to some previous reports, no evidence was found that patients who are hypersecretors of acid, either basal or maximal, before operation should be treated by vagotomy combined with antrectomy. After HSV, however, patients with recurrent DU secreted more acid (basal, insulin and pentagastrin-stimulated) than patients without recurrence, the difference between the two groups being statistically significant for basal acid output (BAO) and the response to insulin. The only factor which was found to influence the incidence of recurrent ulceration after HSV strongly was the surgeon who performed the operation.