Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 68, Num. 4, 2006, pp. 235-235

Indian Journal of Surgery, Vol. 68, No. 4, July-August, 2006, pp. 235

Letter To Editor

Long-term follow-up after peptic ulcer surgery: A need for reopening the old

Nambiar Rajesh, Jeyasingh R, Ashok L, Jayanthi V

Stanley Medical College, Hospital, Chennai

Correspondence Address:Stanley Medical College, Hospital, Chennai Email: drjayanthi35@yahoo.co.in

Code Number: is06070

Sir,
Surgery for peptic ulcer disease in the present days is restricted to complications, namely, perforation, refractory bleed and gastric outlet obstruction. Complications following gastric surgery are not uncommon. Approximately 10 to 15% are severe and revision surgery at times becomes mandatory.[1]

We studied 62 patients with gastric surgery for Visick′s staging and dysplasia in the peristomal region. A second-look surgery with intent to correct was performed in specific situations. All patients had an upper endoscopy with a four quadrant peristomal biopsy. Barium meal study was done in those with diarrhea and in whom endoscopy was noncontributory. A second-look surgery was done in those with Visick′s III and IV and in those who were willing to undergo revision surgery.

The male to female ratio was 5.2:1. The mean age for men was 43.5 years and for women 55.7 years. In the past, all but 5 patients had a truncal vagotomy and gastrojejunostomy. Two patients had pyloroplasty with vagotomy. Surgery was elective in all the patients. The indications were gastric outlet obstruction in 10 patients and intractable ulcer symptoms including bilious vomiting in the rest. The average symptom-free interval following surgery was 10.3 years. In 2 patients, there was no relief from symptoms following surgery.

Paraumbilical and left hypochondrium pain was predominant in 33 patients and associated with recurrent bilious vomiting in 22. These individuals were managed with antacids and prokinetics. Intractable diarrhea was present in 8 patients. Five patients with recurrent ulcer had melena. Progressive weight loss was significant in 22 patients and one patient had classical features of gastrojejunocolic fistula (>12 kg weight loss), 15 years after surgery. None of the patients had late dumping syndrome. Sixteen patients had significant pallor and 3 had pedal edema.

Endoscopically, 35 patients had bile gastritis with brisk bile reflux through the afferent loop (56.4%); twelve patients had a stomal ulcer (19.3%). There were 2 patients who had an afferent loop obstruction (3.3%); one had a gastrojejunocolic fistula (1.6%) and 6 patients had stump carcinoma in (9.6%). Pylorus and duodenum were deformed in 8 and 32 patients respectively. The lumen was narrowed and stenosed in 16 patients. The duodenum was normal in the rest. Six patients had incidental gallstones (9.6%).

None of the patients belonged to Visick′s Grade I. There were 12 cases in Grade II, 13 in Grade III and 19 cases belonged to grade IV.

Histologically, pertistomal biopsy was normal in 8%; 74% had atrophic gastritits, 48% had intestinal metaplasia and 6 patients had an adenocarcinoma with adjacent areas showing intestinal metaplasia. Glandular cystic changes were seen in 24%.

Revision surgery was done in 4 patients with alkaline reflux gastritis. In 2 patients, the gastrojejunostomy was disconnected and converted into a Roux-en-Y in one and jejunojejunostomy in the other. In one patient with efferent loop obstruction, a new stoma was created and in one with afferent loop obstruction, a Roux-en-Y connection was made. One patient with gastrojejunocolic fistula had excision of the fistula, distal gastrectomy with resection of the involved segment of colon and jejunum, with reanastomosis of the disconnected segment. Of the 2 patients with stump carcinoma, one was inoperable and the other had a distal gastrectomy with Bilroth II anastomosis. In one patient with ulcer perforation, closure with peritoneal lavage was done.

The introduction of powerful proton pump inhibitors has significantly reduced the incidence of peptic ulcer surgery in the recent years. The present study was a prospective one amongst patients attending the gastroenterology department for over 2 years. While the present study has looked into the comorbid symptoms in patients undergoing surgery for an ulcer disease and attending the hospital, a large number are likely to be asymptomatic. Despite this, a large number of cases present to the outpatient with severe bile reflux gastritis and diarrhea. Many of these do not respond to medical therapy and often require revision surgery as was shown necessary in this study.

References

Copyright 2006 - Indian Journal of Surgery