Gastroduodenal Ulcer

By the early part of this century, members of the Southern Surgical Association as well as others began to realize that gastroenterostomy alone was unacceptable for the treatment of gastric ulcer. Ulcer excision and some type of limited resection was advised. At a later date, gastric resection of varying extent, depending on ulcer size and location, became the appropriate treatment for complications of this disease. For treatment of complications of duodenal ulcer, gastroenterostomy was widely used from the latter part of the 19th century until the late 1930s. Adequate gastric resection slowly but cautiously replaced gastroenterostomy during the 1940s. Vagotomy with drainage and vagotomy with antrectomy slowly developed and replaced adequate resection by the early 1970s. Beginning in the 1970s and extending into the 1980s, fewer duodenal ulcers were seen, and many of those encountered were being adequately managed using the H2 receptor blockers. For the intractable duodenal ulcer there is currently an increasing trend to use the less invasive operation of parietal cell vagotomy. Vagotomy with antrectomy for such cases is being used less frequently. Vagotomy and drainage has lost much of its appeal. Lesser procedures have been advocated recently for treatment of marginal ulcer after incomplete vagotomy irrespective of the original operation for ulcer. Massive bleeding and acute perforation are still frequently encountered as complications but are being seen more frequently in elderly high-risk patients, some of whom will tolerate only a lesser procedure as suture ligation, vagotomy with drainage, or simple ulcer closure. It appears that we are now seeing a different duodenal ulcer pattern in the good-risk patient. The ulcers are usually small, less virulent, and less likely to be found penetrating into the pancreas and adjacent organ structures. As Claude Welch so aptly stated recently before the Association, "We are seeing a trend in ulcer surgery that is currently being seen in other areas of surgical endeavors as well." He emphasized that we must be alert to changing disease patterns and adapt our procedures to new requirements.