A debate: we should seldom operate on uncomplicated duodenal ulcer.
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Biomedical subjects
Publications and source records attributed to V H Cumberland.
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Sixty-six patients having surgery for recurrent peptic ulcers over a 10-year period are reviewed. The majority of the patients were male and developed their initial ulcers at an early age. Bleeding was the most common presenting symptom. Seventy-one percent of the recurrences occurred within three years. Barium meal X-ray examination plus endoscopy gave the correct diagnosis in 96% of cases. The causes of the recurrent peptic ulcers were: (1) incomplete vagotomy; (2) inadequate gastric resection; (3) inappropriate surgery; (4) Zollinger-Ellison syndrome; (5) gastric outflow obstruction; and (6) bile reflux. Other factors such as alcohol, analgesic abuse and psychiatric disorders were found to be common associations. Resection plus vagotomy was the summation of primary and secondary surgery in 85%. The operative mortality was 3%. Eighty-five percent of patients had a Visick grading of I or II. Only one patient had a further recurrent ulcer and this healed on medical treatment.
The results for the first 101 consecutive patients who had selective vagotomy and a drainage procedure performed for duodenal ulceration between 1967 and 1971 are presented. Seventy-four patients were followed up for five to nine years, 13 patients were lost to follow-up for part of the five-year period, and 14 patients died during follow-up. Six patients developed recurrent ulcers. Five of these recurrent ulcers were observed in patients in whom the vagotomy was not tested for completeness during the operation; this represents a recurrence rate of 10%. One patient, in whom testing was used at operation, developed a recurrent ulcer; this represents a recurrence rate of 2%. There was a statistically significant difference in the rate of recurrence between the group tested during operation and that not tested.
The occurrence of acute pancreatitis in gastric aberrant pancreas is described. The patient presented initially with acute abdominal pain and a palpable epigastric mass. The symptoms were severe and recurrent, and laparotomy with antrectomy was required.
Colorectal mucosa from patients with colorectal carcinoma was compared with rectal mucosa from a control group. It was found that the LDH isoenzyme pattern of uninvolved mucosa proximal and distal to the carcinoma differed from that of normal tissue and resembled that of carcinoma tissue except in the case of the uninvolved mucosa proximal to the carcinoma of the sigmoid colon, which did not differ from normal mucosa.
A prospective study of the surgical management of 100 consecutive patients with benign, non-variceal upper gastrointestinal bleeding is presented. The manner of presentation, precipitating factors, investigations and associated medical problems are discussed. Chronic duodenal ulceration was the most common cause of haemorrhage. Vagotomy and drainage with oversewing or excision of the bleeding ulcer was the surgical procedure performed in 71 of the patients in the series. The incidence of recurrent bleeding was 7%; no patient in this category required further operation. The mortality rate was 6%, and there were no deaths recorded in the patients who underwent vagotomy and drainage. The reasons for the relatively low surgical mortality are discussed.
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In a series of 100 consecutive patients who had parietal cell vagotomy performed, no drainage procedure was performed in 56 while 44 were drained. Dumping was significantly less in those who were not drained. All patients were tested for adequacy of vagotomy and for function of the nerve of Latarget at operation. Four patients have had further operations, two for proven recurrent ulcers. Parietal cell vagotomy has given excellent clinical results in this group of patients.
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Serum gastrin has been measured in 30 patients following selective gastric vagotomy. Basal serum gastrin was 52+/-5.7 pg/ml which was significantly lower than the corresponding level in 50 patients following truncal vagotomy (84+/-7.9 pg/ml). After a standard protein meal serum gastrin rose to 136+/-8.3 pg/ml at 60 minutes after the meal. The peak rise above basal levels was significantly lower than that achieved in patients who had undergone truncal vagotomy. These results complement our previous hypothesis that section of extragastric vagal fibres permits the release of additional gastrin above that expected with the diminution of acid secretion, and hence the decrease in inhibition of gastrin release from the antrum.
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