Surgery or cimetidine? I. Comparison of two plans of treatment: operation or repeated cimetidine

The effects of cimetidine on the cost of ulcer disease in Sweden

The economic impact of the drug cimetidine on the direct and indirect costs of ulcer disease was studied. Cimetidine appeared on the Swedish market in 1978. Unlike other innovations, whose spread is normally slow during the initial period, cimetidine was introduced very swiftly and its use quickly expanded. It was expected that it would reduce the number of elective ulcer operations, with resulting savings in medical care resources exceeding the cost of the new drug. The use of cimetidine was also expected to reduce the indirect costs related to short- and long-term illness. The aims of the study were: (1) to describe and calculate the economic impact of the introduction of cimetidine; (2) to compare the retrospective calculations with the prospective calculations; and (3) to investigate how routinely collected data could serve as a complement to studies of efficacy, effectiveness, and cost-effectiveness. Retrospective calculation of the economic effects shows that cimetidine has in fact increased the direct costs of medical care. On the other hand, the drop in indirect costs due to reduced long-term absence (disability) from work, and reduced short-term absence from work, exceeded the increase in the cost of medical care. Thus, the total economic cost of peptic ulcer disease was reduced.

Changing pattern of admissions and operations for duodenal ulcer

The admission rates for duodenal ulcer (DU) and the effect of H2-receptor antagonists (H2RA), introduced in the Trent Region of the UK in 1977, were examined. The admission rates are expressed per 10(6) of resident population. The use of H2RA has risen 3.7-fold (from 1978 to 1983), yet overall admission rates for perforation have changed little: 99 in 1972-76 (pre-H2RA period) compared with 103 in 1977-84 (H2RA period). Admission rates for haemorrhage have risen by 8 per cent, from 130 to 140 (P less than 0.01). However, the overall rates conceal large increases (P less than 0.01) in the admission rates for those aged greater than or equal to 65 years, of 33 per cent (from 264 to 352) for perforation and of 28 per cent (from 381 to 489) for haemorrhage. Emergency admissions for uncomplicated DU were unchanged: 88 in 1972-76 and 89 in 1977-84. However, the proportions operated on fell by 58 per cent (P less than 0.01), from 30 per cent of admissions in the pre-H2RA period compared with only 12 per cent in the H2RA period. Waiting-list admissions for uncomplicated DU fell by 43 per cent, from 187 to 106 (P less than 0.01), and the proportions operated on fell from 162 to 76; the combined effect resulted in a reduction of 53 per cent in the operation rates (P less than 0.01). In Rotherham, the use of H2RA has risen 6.2-fold (from 1978 to 1983) and they were generally used intermittently in 1976-78 and later for maintenance therapy and high-dose treatment. Yet admissions for perforation and for haemorrhage were unchanged. Emergency admissions for uncomplicated DU rose by 40 per cent, from 130 in 1972-75 to 182 in 1976-84, but the proportions operated on fell markedly, from 20 to 6 per cent (P less than 0.01); waiting-list admissions fell in 1976-78 by 29 per cent and in 1979-84 by 73 per cent. The proportions operated on in the three periods fell from 74 to 53 per cent and 25 per cent respectively and these two factors led to decreases in elective surgery of 50 per cent in 1976-78 and 91 per cent in 1979-84 (P less than 0.01).(ABSTRACT TRUNCATED AT 400 WORDS)

Surgery is preferable in patients with severe chronic peptic ulcer disease

Conservative treatment given as interrupted courses is easy and successful for the majority of patients with peptic ulcer disease. For those plagued for years and years by severe chronic complaints the choice will be maintenance treatment or surgery. Maintenance treatment possibly spares the patient for an operation but includes a risk of stenosis claiming the necessity of a drainage operation with risk of sequels. The taking of the pill means a daily remembrance of the disease. Relapse rate is high. The economic problem is not unimportant for the patient. When contra indications are taken seriously into consideration modern ulcer surgery is not dangerous. There are no sequels if the pyloric function can be left intact. The cured patients feel fit and will usually forget the disease. Recurrence rate is lower than that during maintenance therapy but if occurring early they may be difficult to treat. The young patient with severe chronic duodenal ulcer disease should not wait eternally for a parietal cell vagotomy. When the ulcer is located to the pyloric channel prolonged conservative treatment may be advisable. Treatment policy for the gastric ulcer is debatable. No treatment is yet ideal. The advice to the individual patient should be based upon a non-prejudiced evaluation of the advantages and disadvantages of the therapeutic possibilities necessitating that the gastroenterologist and the surgeon have a thorough knowledge of the results of the other speciality.

[Initial interventions in ulcer disease: indications--choice of procedure--results]

Routine use of H2 receptor blockers in the therapy of chronic gastroduodenal ulcers reduced the number of ulcer operations. The ulcer recurrence rate in postpyloric and duodenal ulcer seems to be lower after highly selective vagotomies than during long term maintenance treatment, prepyloric ulcers are treated best by gastric vagotomy and antrectomy. In the absence of risk factors perforated gastroduodenal ulcers are treated better by definitive surgery (suture plus vagotomy) than by simple suture.

Should it be parietal cell vagotomy or selective vagotomy-antrectomy for treatment of duodenal ulcer? A progress report

This is a progress report of a prospective, randomized study involving 200 consecutive patients treated electively with either parietal cell vagotomy (PCV) or selective vagotomy and antrectomy (SV-A). Both groups comprised patients with pyloric, prepyloric, or duodenal ulcers. There was no operative mortality in either group. Patients were examined at 2, 6, 12 months, and every 12 months thereafter for 8-10 years. The two operations produced no statistical difference in the frequency of diarrhea. Dumping (p less than 0.0005) and weight loss (p less than 0.0005-p less than 0.05) were statistically less after PCV than after SV-A. There were two recurrent ulcers (2.2%) after SV-A. One was treated successfully by medical therapy and one patient suspected of having gastrinoma had total vagotomy. Nine patients had recurrent ulcers in the PCV group for an accumulated recurrence rate of 10.1% at 10 years by life-table analysis. There was a significant difference (p less than 0.033) between the curves for recurrent ulcers in the two groups of patients. The recurrent ulcer rate after PCV was 21% for patients with pyloric and prepyloric ulcers and 6% for patients with duodenal ulcer. There was no significant difference between the recurrent ulcer rate for PCV and SV-A if the patients with pyloric and prepyloric ulcers were withdrawn from the study. Of the nine patients with recurrent ulcers in the PCV group, three had an inadequate vagotomy and four had a pyloric or prepyloric ulcer before operation. Three patients were successfully treated with antrectomy. Five patients were treated successfully by medical therapy and remained healed for long periods without recurrence. One patient had five recurrences. He declined operation and remained free of symptoms for 3 years after his last recurrence. Poor gastric emptying necessitated gastroenterostomy in five patients in the SV-A group and in one patient in the PCV group. Patients' clinical results were evaluated according to a simple Visick grading scale. A significantly (p less than 0.0005) greater number of patients were in Visick I category after PCV than after SV-A. The clinical results obtained with PCV make this the operation of choice for the elective surgical treatment of duodenal ulcers even though the results obtained with SV-A were good.

Results of long-term treatment with cimetidine

Forty-two patients, 35 with duodenal ulcer, 6 with prepyloric ulcer, and 1 with gastric ulcer, were, in accordance with their own choice, allocated to either maintenance therapy with cimetidine or intermittent therapy in connection with symptoms and endoscopically proven relapse. Dosage during maintenance therapy was kept as low as possible to keep patients free of symptoms. Patients receiving maintenance therapy were mostly free of symptoms, but 6 out of 24 patients had from one recurrence every 2nd year to 3 recurrences per year. Patients receiving intermittent therapy had two recurrences per year (median). The yearly dose of cimetidine in maintenance therapy was high (219 g; range, 73-292 g) compared with 59 g (range, 42-84 g) in intermittent therapy. To conclude, we cannot recommend the use of maintenance therapy for years in the routine management of ulcer patients.

Ulcer healing and relapse prevention by ranitidine in peptic ulcer disease

Ranitidine, 300 mg daily, was given to 92 patients with duodenal ulcer (DU), 38 with prepyloric ulcer (PPU), and 21 with gastric corporeal ulcer (GCU). The healing rates at 4 weeks differed for the different types of ulcers (P less than 0.01), being 91% for DU, 68% for PPU, and 81% for GCU. After established ulcer healing, maintenance treatment with either ranitidine, 100 mg twice daily or 150 mg at night, or placebo was given for 1 year or until ulcer relapse in a total of 108 patients--71 with DU, 24 with PPU, and 13 with GCU. There were no significant differences in relapse rates between the two groups treated with active drug or between the three ulcer groups. However, the overall relapse rate in the active drug groups was 16%, against 72% in the placebo group (P less than 0.001).

Deaths from peptic ulceration

Deaths due to peptic ulceration can be prevented only by curing the ulcer and preventing the ulcer diathesis permanently by either medical or surgical means. Recurrence of ulcers after drug treatment is a major problem, so continuous treatment is often necessary, but there is no evidence that this decreases mortality. Surgery is the only means of permanently removing the ulcer diathesis in most patients, and subsequent mortality is low. A reasonable balance has to be achieved between the two kinds of treatment to prevent most deaths from peptic ulcer.

Prevention of ulcer recurrence--medical vs surgical treatment. The surgeon's view

The need for surgical intervention in duodenal ulcer disease will undoubtedly decrease in the years to come. Occasional failure of medical treatment and persistent doubts about the long-term safety of anti-ulcer drugs will continue to make operation the treatment of choice for some patients, however. Long-term medical treatment and surgery can be considered equally acceptable options for most patients. When operation is considered necessary, parietal cell vagotomy fits the requirements of a modern surgical method better than other techniques. The effective medical treatment now available makes postoperative recurrence of ulcer less important than before and lack of postoperative symptoms has replaced fear of recurrent ulceration as the main concern in the value judgement of both doctors and patients.

Cimetidine or parietal-cell vagotomy in patients with juxtapyloric ulcers

83 patients with severe juxtapyloric ulcers were randomly allocated to either long-term cimetidine treatment (400-800 mg/day) or to parietal-cell vagotomy (PCV). All were followed up for more than 3 years. The endoscopically proven relapse-rate with a dose of 400 mg at bed time was 54%; it fell to 32% when the dose was increased to 400 mg twice a day. In the PCV group the relapse-rate was 33%. Patients with prepyloric ulcers alone or in combination with duodenal ulcers relapsed at a higher rate (57% and 82%, respectively) than did patients with "pure" duodenal ulcer disease (17% and 14%, respectively). No patient, not even those with a history of bleeding or perforated ulcers, experienced any bleeding or perforation during relapses, either when on long-term cimetidine treatment or after operation. Previous haemorrhage or perforation per se is thus not an indication for surgery in favour of maintenance treatment with cimetidine.

Failure of proximal gastric vagotomy for duodenal ulcer resistant to cimetidine

45 patients with uncomplicated duodenal ulcer who did not respond to cimetidine underwent elective proximal gastric vagotomy (PGV). 39 of these, who had received cimetidine for an average of 5.2 months before surgery, were followed up for 20-67 months postoperatively. 18(46%) of them were classified as grade IV (ie, failures) according to a modified Visick scale--17 (44%) had a recurrent peptic ulcer. Augmented histamine tests done in 17 patients showed an expected reduction of peak acid output, so maintenance of stomach acidity was unlikely to be a cause of failure of the operation. The presence of mental and social problems preoperatively was associated with a postoperative Visick grade IV. Despite repeated medical therapy, and reoperation in 6 patients, 10(26%) patients still had severe pain and/or dumping at follow up. Proximal gastric vagotomy cannot be advocated in patients with uncomplicated duodenal ulcer resistant to cimetidine, and an alternative treatment is needed for these patients.