Delayed ulcer recurrence after gastric resection: a new postgastrectomy syndrome?

Recurrent ulceration following gastrectomy for peptic ulcer disease typically occurs within the first several years postoperatively. Since 1990, we have managed 20 patients who had undergone previous gastrectomy for peptic ulcer and developed ulcer recurrence more than 10 years postoperatively. Mean age at recurrence was 64 years, and the average time from original surgery to recurrent ulceration was 21 years (range, 10-36 years). All patients had undergone vagotomy and antrectomy (17 patients) or subtotal gastrectomy (3 patients). Presenting symptoms included gastric outlet obstruction (70%) and bezoar formation (60%). Endoscopic findings in this group of patients included a stenotic gastric outlet (70%) and marginal ulcerations (80%). Thirteen of 15 patients tested (87%) were Helicobacter pylori positive. Reoperation included partial resection of the gastric pouch and exploration for persistent vagus nerve. Twelve patients underwent Roux-en-Y reconstruction, whereas eight patients had Bilroth II reconstruction. Three of the latter group also had Braun enteroenterostomy performed. Good to excellent clinical results were obtained in 80 per cent of patients. The four patients with poor outcomes shared the following characteristics: 1) H. pylori-positive status, 2) presence of a preoperative bezoar, 3) Roux-en-Y reconstruction. Our current approach is to avoid Roux-en-Y construction in favor of Braun enteroenterostomy. Further prospective analysis of long-term postgastrectomy patients is needed to determine whether this clinical picture represents a new postgastrectomy syndrome.