Changing trends in the surgical treatment of duodenal ulcer.

On the basis of fully or partly controlled clinical trials the long term results of several standard operations for duodenal ulcer have been compared--subtotal gastrectomy, truncal vagotomy and antrectomy, truncal vagotomy and gastro-enterostomy, truncal vagotomy and pyloroplasty, selective vagotomy and pyloroplasty and proximal gastric vagotomy without drainage. Few statistically significant differences emerge but the following observations seems to be justified: (a) Subtotal gastrectomy and vagotomy and antrectomy probably offer better protection against recurrent ulceration than any of the other operations examined, but the greater intrinsic operative risks of these two resection procedures is emphasized. (b) Disturbances of alimentary function occur to a variable extent after all operations but appear to be least troublesome after proximal gastric vagotomy without drainage. In particular this operation is followed by a negligible incidence of diarrhoea compared with truncal vagotomy procedures. (c) On overall (Visick) grading the two resection operations and proximal gastric vagotomy without drainage do better than truncal vagotomy with drainage, proximal gastric vagotomy being specially notable for the relatively small proportion of patients in category 3 after its use. Surgical strategy in the choice of elevtive operation for duodenal ulcer is discussed.