Effect of the pre-operative response to H2 receptor antagonists on the outcome of highly selective vagotomy for duodenal ulcer.

From 1979 to 1984, 141 consecutive patients (110 men, 31 women) underwent highly selective vagotomy (HSV) for duodenal ulcer (DU). All patients had received pre-operative treatment with full dose H2 receptor antagonists (H2RA). Indications for surgery were: persistent relapse on withdrawal of H2RA, 107 (75.9 per cent); no response to H2RA, 30 (21.3 per cent); intolerance of H2RA, 1 (0.7 per cent); acute DU bleed, 2 (1.4 per cent); duodenal stenosis, 1 (0.7 per cent). Follow-up with a median of 47 months (24-85 months) revealed six patients (4.4 per cent) with endoscopically proven recurrence, three of whom were on non-steroidal anti-inflammatory drugs (NSAIDs). Only one patient with recurrent DU was a non-responder to H2RA pre-operatively. Twenty-five patients remained symptomatic after HSV without ulcer recurrence, of which a highly significant proportion (41 per cent) were non-responders (P less than 0.001). The pre-operative response to H2RA does not indicate the likelihood of ulcer recurrence after HSV. However, non-responders are more likely to continue with dyspeptic symptoms despite the successful healing of their ulcers. The DU recurrence rate in patients taking long-term NSAIDs is disappointingly high (33 per cent), putting the use of HSV in these patients into question.