Recurrent peptic ulcers

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Abstract
This article is concerned mainly with recurrent ulceration (RU) after vagotomy [truncal (TV), selective (SV), or highly selective (HSV)]. RU may be symptomatic or asymptomatic. Since few surgeons routinely perform endoscopy on asymptomatic patients, it is symptomatic RU that is being discussed.After all 3 types of vagotomy, without antrectomy, median incidences of RU are about 10% after 5–10 years, but there is wide variation, from 1% to 30%. There is no convincing evidence that TV denervates the parietal cell mass more effectively than does SV or HSV, or that it has a lower incidence of RU than SV or HSV. Claims that SV and HSV lead to fewer incomplete vagotomies and less RU than TV are, however, not convincing. Since SV + P (pyloroplasty) or gastrojejunostomy (GJ) carries the same risk of RU as HSV, but has more side effects because of loss of the pylorus, it has been abandoned. The choice of elective operation for duodenal ulcer (DU) thus lies among TV + D (truncal vagotomy + drainage procedure), HSV, and V + A (vagotomy + antrectomy).The results of 5 controlled trials suggest that HSV yields better overall clinical results than V + A, even though the incidence of RU is 1% after V + A compared with 10% after HSV. Even for patients with hypersecretion of acid, V + A should not be employed in preference to HSV, because incidences of RU after HSV are no higher among hypersecretors of acid than among normal secretors. Gastrin cell (G‐cell) hyperplasia and “antral dominance” are concepts still too nebulous to influence the choice of elective operation for DU.After complete vagotomy (TV, SV, or HSV), as shown by the Burge, Grassi, or Hollander tests, the incidence of RU is 2–5%. High incidences of RU are not related to any characteristic of the patient, the level of acid output, or the ulcer, but are related to the surgeon who operates. They are thus related to operative technique, and are preventable.Despite the advent of H2‐receptor antagonists, elective vagotomy (preferably in the form of HSV) still has a place in the management of DU because it is more effective than H2‐blockers in lowering intragastric acidity permanently and in preventing recurrent ulceration.