Nine cases of gastric ulcer after vagotomy and drainage for duodenal ulcer.

Gastric ulceration was recognized as an occasional complication of vagotomy soon after Dragstedt championed the operation for the treatment of duodenal ulceration (Dragstedt and Owens, 1943). Gastric atony and antral stasis were to be expected after vagotomy without adequate drainage of the gastric contents and it was perhaps not surprising that a number of patients should have developed lesser curve gastric ulceration after vagotomy alone. The mechanism responsible for the development of gastric ulceration in these circumstances was later considered to be due to gastric retention, antral stasis and alkalinization, and gastrin release, with the resulting continual gastric acid stimulation (Dragstedt, 1953; Burge, 1964; Oberhelman, 1964). The occurrence of gastric ulceration after vagotomy lent further support to Dragstedt's well known postulate that all gastric ulceration was dependent on the hormonal phase of gastric secretion consequent upon antral stasis and 'hyperfunction or dysfunction of the gastric antrum' (Dragstedt, 1953, 1956). Other workers have not noted a significant difference in gastric emptying between duodenal and gastric ulcer patients (Buchler, 1964; Griffith, Owen, Campbell, and Shields, 1968). Vagotomy combined with an adequate and truly dependent drainage procedure was found to prevent, or in fact heal, gastric ulceration (Dragstedt, 1952; Burge, 1964, 1966). This led many workers to consider the drainage procedure to be the most important single procedure in effecting healing of these gastric ulcers, the vagotomy serving to reduce the vagal and antral phase of acid secretion. It also explained the excellent results with gastroenterostomy alone in the treatment of gastric ulceration in many patients. Recently Burge and others have revived vagotomy and drainage as a curative operation for lesser curve gastric ulcers and Burge reiterated the importance of adequate drainage (Burge, 1964, 1966; Dragstedt, 1966; Kennedy and George, 1967). Since the adoption of vagotomy and drainage, either gastroenterostomy and more recently the popular operation of pyloroplasty, as the operation of choice for duodenal ulcer in the majority of surgical centres, little has been written about recurrent gastric ulceration after these procedures (Bockus, 1964; Burge, 1964; Stitt, O'Sullivan, and Currie, 1966). Most attention has been directed to the incidence of recurrent jejunal or duodenal ulceration and their relationship to incomplete vagal section (Burge, 1964; Ross and Kay, 1964; Bank, Marks, and Louw, 1967). Burge (1964) tends to disregard gastric ulceration aftervagotomy and drainage, dismissing its occurrence as due to an inadequate drainage procedure or to transient gastric stasis caused by a denervated stomach, the ulcer healing as gastric tone recovers. The purpose of the present paper is to present nine patients who developed gastric ulceration after vagotomy and drainage for duodenal ulceration, and to emphasize the importance of considering this occasional development in patients with recurrent dyspepsia or bleeding despite a seemingly adequate drainage procedure and an apparently complete vagotomy.