1. Gecompliceerd Ulcuslijden Bloedingen en Perforaties H.W. Tilanus 31 Januari 2006, Delft

2. “If Anyone should consider removing half of my stomach to cure a small ulcer in my duodenum I would run faster than he”  Charles E. Mayo, 1927

3. History of Vagal Pioneers  Ivan Pavlov : acid secretion in dogs (1904)  Andre Latarjet : vagotomy inhibits emptying (1921)  Lester Dragstedt : vagotomy and pyloroplasty (1945)  Farmer and Smith : recurrence after VT+A: < 16%(1952)

4. Ivan Petrovic Pavlov  Surgical diversion of the esophagus of the dog  Production of 700 ml “gastric juice” after sham feeding  Dramatically reduced after bilateral vagotomy  Production restored after electric vagal stimulation  “The effect of feeding is transmitted by nervous channels to the gastric glands” Pavlov IP. The work of the digestive glands London, Griffin 1902,48

5. Ivan Pavlov (1849-1936) performing an experimental vagotomy

6. Andre Latarjet (1876-1947)  First human vagotomy 1921  All extrinsic nerves to stomach and duodenum severed  24 patients presented to the “Academy de Chirurgie”  Delayed gastric emptying  Failed to gain widespread support  By 1940 fewer than 100 operations performed Latarjet A.: Bull Acad Natl Med 1922;87:681

7. Stomach surgery in the Netherlands.1908

8. Predominance of “Gastrectomists”  Billroth, von Eiselsberg, Moynihan advocated resection  Diminished interest in vagotomy  Resection controls the ‘three factors in ulcerogenesis’:  1: the specific ulcer gastritis  2: existence of free hydrochloric acid in stomach  3: secondary infection with green streptococcus  Vagotomy “was not practiced for the next 20 years”  Klein E. Ann Surg 1929; 90:65  Berg A. Ann Surg 1930; 92:340 

9. 1881: Billroth performing a stomach resection (A.Seligmann)

10. von Eiselsberg at work in University Hospital, Utrecht 1898

11. Lester Reynolds Dragstedt 1893-1975  Born 22 october 1893  Modest background and minimal education.  Rose to the pinnacle of American surgery and science  Internationally known for research on gastric physiology  Introduced vagotomy as safe procedure for peptic ulcer disease.  Honored by numerous national and international surgical societies.  Loved by his patients and students.

12. Lester Dragstedt (l) with brother Carl in 1918

13. Dragstedt’s first vagotomies  Abnormally secretion at night during empty stomach  Neural stimulation causes increased output of juice:  Fasting hypersecretion by neural or ‘hormonal’ stimulation  Hormone: gastric secretine or gastrine  First vagotomy in 35 year old patient refusing resection  Followed by 200 thoracic vagotomies in next 4 years  ‘Gastrostasis’ only ‘temporary’ Dragsted L Owens F Proc Soc Exp Biol Med 1943;53:152 Dragsted L Ann Surg 1947; 126:687

14. Dragsted LR, Am J Surg 1974;128:344

15. Vagotomy and hemigastrectomy  Farmer and Smith (1952):  Vagotomy with hemigastrectomy superior.  93% gastric pH < 3.5 Farmer and Smith N Engl J Med 1952:247:1071  Edwards and Herrington (1953):  200 vagotomies with 40% gastrectomy  Excellent results in 93.4% Edwards LW and Herrington JL Ann Surg 1953:137;873

16. Refinements in Vagotomy  Single layer pyloroplasty (n=500)  Weinberg et al, Am J Surg 1956;92:202  More selective vagotomy  Griffith C et al, Gastroenterology 1957;32:  Parietal cell vagotomy  Holle F, Hart W, Med Clin, 1967;62:441  Maintaining the antral innervation  Johnston D et al’ Br.J Surg 1969;69:626  Superficial seromyotomy, truncal left vagotomy (Taylor II)   Taylor T, Br J Surg, 1979;66:733 

17. Various teDevelopment of vagotomy 1814-1979of the

18. Etiology of ulcer perforation  Smokers have 3 fold higher mortality  Doll R et al. Br Med J,1994;309:901  Accounts for perforation in >70% in patients <70 yrs Svanes C et al.Gut,1997;41:177  NSAID’s contributes one-fifth to one-third to perforations Svanes C et al. 1996;  Major role of H.pylori in perforations not confirmed Reinbach DH et al, Gut,1993;34:1344

19. Incidence of Perforated Ulcer Disease  Rare during 19th century  Sharp increase at turn of twentieth century  Since then epidemic of duodenal perforations is waning  In men: increase until 1950 and declined thereafter  In women: slow increase after 1950  Increasing age among ulcer perforation patients   Svanes C et al.,Am J Epidmiol. 1995;141:836

20. Incidence of ulcer perforation Svanes et al. Am J Epidemiol 1995;141:836

21. Incidence of Perforated Ulcer Disease  No fall of complications after H2-blocker  Alalgaratnam et al. J Clin Gastroenterol. 10:25, 1988  No fall in era of H.Pylori eradication  Liu et al. Asian J Surg 20:305, 1997  Significant reduction in only one study  Hermansson et al. Scand j Gastroenterol 32:523, 1997  Conservative management warrants consideration 

22. Bio-rhythms of Ulcer Perforation  Typical and dramatic onset: time can be assessed  Consistent daily variation is reported  Greater incidence during the day, decreasing during night  No change since first report in 1903  Duodenal perforations: peak: afternoon and evening  Gastric perforations: peak: midday and night  Jamieson RA, Br.Med. J. 1955;2:222  Hennessy E,Aust N.Z.J.Surg.1969;38:243  Svanes C et al. Int J Chronobiol 1998;15:241

23. Numbers and time of perforations: A: Gastric B:Duodenal

24. “Once the perforation has occurred, the case must be considered hopeless……. In surgery’s present state the idea of cutting open the abdomen and closing the opening would be too quixotic to mention…” Edward Crisp, 1842

25. Non-surgical approach of perforated ulcer  Mortality rate of surgical treatment: close to 20%  Resuscitation with intravenous fluids  Intravenous antibiotics  Nasogastric suction  Taylor, H.: Lancet 1956,14;270:397

26. Perforated ulcers-controlled trials  Conservative management vs emergency surgery:  Surgical group: n=43  24 omental patch; 15 V+P; 4 partial gastrectomies  Conservative group: n=40  11 patients (27%) underwent surgery after 12 hours  No difference in morbidity or death (2 vs 2)  Conclusion: place for conservative treatment   Crofts et al. N.Engl. J. Med. 320:970,1989

27. Perforated ulcers- controlled trials  Simple closure vs. definitive surgery: 3 Trials:  Patients with risk factors excluded:  328 patients included, one death overall  Morbidity equal in groups: 11% chest infections  Difference in recurrence: 61% after simple closure  6% after definitive surgery Boey et al. Ann.Surg.196:338, 1982 Hay et al. World.J.Surg.12:705,1988 Tanphiphat et al. Br.J.Surg.72:370,1985

28. Een maagoperatie in het Zuiderziekenhuis, Rotterdam

29. Risk factors and operative mortality  Operative mortality for perforated ulcer is about 5%  30% or higher has been reported Co-morbidity: cardiac; COPD  Delay of presentation > 24 hrs.  Shock on admission   Boey.J.et al. Ann. Surg. 205:22,1987  Blomgren L. et al. World J.Surg.21:412,1997  Irvin T. et al. Br.J.Surg.77:1006,1990

31. Lethality and complications after perforation according to treatment delay during periods ’35-50, ’51-’70, ’71-’90

32. H.pylori and perforated ulcer  H.pylori is positive in 70-80% of operated patients  H.pylori 55% prevalence in population  Urea breath test positive in 24 of 29 of patients  Urease test on biopsy positive in 12 of 14 patients  In NSAID- patients no association with H.pylori   Matskura N. et al. J.Clin.Gastroenterol. S235,1997  Ng.E. et al. Br.J.Surg. 83: 1779,1996  Sebastian M. et al. Br.J.Surg.82:360,1995  Reinbach D. et al. Gut 34:1344, 1993 . 

33. “If Anyone should consider removing half of my stomach to cure a small ulcer in my duodenum I would run faster than he”.  Charles E. Mayo, 1927

34. Conclusions  High recurrence rate after simple closure  <40 yrs. NSAID neg. may benefit from conservative R/  >40 yrs.: (laparoscopic) surgery  NSAID neg. patients: H.pylori-eradication  Intractable DU adequate R/: definitive surgery  Patients with risk factors: simple closure Millat B,et al. World J. Surg. 24,299,2000 