Surgery or cimetidine? II. Comparison of two plans of treatment: operation or cimetidine given as a low maintenance dose

Efficacy of continuous therapy for peptic ulcer in controlled clinical trials

Long-term studies have confirmed unequivocally the clinical efficacy of continuous therapy with H2-receptor antagonists in reducing the incidence of ulcer recurrence. However, studies have also reported varying relapse rates as a result of differences in study design, particularly the frequency of endoscopy and hence the detection of asymptomatic ulcer relapse. Risk factors for ulcer relapse include smoking, stress, previous history of frequent ulcer relapses, duration of disease for more than 10 years and concomitant administration of non-steroidal anti-inflammatory drugs. In the prevention of relapse with H2-receptor antagonists, choice of agents also may influence the rate of relapse. A meta-analysis of data from direct comparative trials indicates that recurrence rates of duodenal ulcer are significantly lower after one year of treatment with ranitidine (150 mg nocte) than with cimetidine (400 mg nocte). It has been claimed that patients with peptic ulcer disease can be successfully managed by intermittent courses of treatment with H2-receptor antagonists which are taken in response to the development of symptoms. However, high relapse rates (64-100%) have been reported during the first year of follow-up of patients who were receiving intermittent treatment with H2-receptor antagonists. High complication rates (haemorrhage 11.4%, perforation 1.2%) have also been reported over a seven-year follow-up, while continuous treatment with H2-receptor antagonists significantly decreases the risk of haemorrhage in the event of ulcer recurrence.

Abdominal and dyspeptic symptoms in patients with peptic ulcer treated medically or surgically

BACKGROUND

Abdominal and dyspeptic complaints, which are prominent symptoms in patients with peptic ulceration, are commonly reported in the general population. There are few reports of follow-up study of peptic ulcer therapies in which clinical outcome has been compared with symptom reporting in community controls.

METHODS

Three populations of patients with peptic ulcer disease (patients who had elective proximal gastric vagotomy (PGV), those having PGV for emergency indications and those receiving medical treatment with H2-receptor antagonists) were included in a questionnaire survey and compared with a group of randomly selected community controls.

RESULTS

The vagotomized patients reported fewer abdominal complaints (P = 0.0003) and fewer dyspeptic complaints lasting for more than 1 week (P = 0.05) than those treated medically. There was no significant difference between vagotomized patients and community controls in the reporting of abdominal (P = 0.2) or dyspeptic (P = 0.9) complaints.

CONCLUSION

Taking abdominal complaints as the endpoint for former peptic ulcer treatment, surgical treatment with PGV seemed to be superior to therapy with H2-receptor antagonists and produced an almost identical level of complaints to that seen in the community population.

The randomized controlled clinical trial in gastroenterology: the Danish contributions from 1970 to 1994

More than 200 Danish randomized controlled clinical trials in gastroenterology published from 1970 to 1994 were retrieved by electronic media, by hand-searching relevant journals, and by direct requests to Danish gastroenterologists. With the historical perspective through a quarter of a century, these papers are outlined to provide a survey of the pieces of information that Danish gastroenterologists have contributed to the present knowledge of therapeutics. The presented randomized controlled clinical trials constitute an impressive sum of knowledge within a diversity of topics. A cautious analysis of the time pattern for the publications in addition to the contents of the reports discloses that the discipline of planning and executing relevant controlled clinical trials is now in blossom in Danish gastroenterology.

Peptic ulcer hemorrhage: factors predisposing to recurrence

Two hundred and eighty patients with stigmata of recent or active bleeding from a peptic ulcer were followed up after endoscopic or conservative medical treatment. Of the patients 53% had no history of dyspeptic symptoms, but 17% and 10% had a history of uncomplicated ulcer or bleeding ulcer, respectively, before the index admission. After 8 years of follow-up the estimated recurrence rate was 29% (95% confidence limits, 12-47%). At recurrence 65% of the patients presented with a rebleed and 12% with a perforation. By means of a logistic regression analysis, a previous history of ulcer haemorrhage was identified as the only predictor associated with a significantly increased risk of recurrence. The recurrence rate in 253 patients presenting with a first bleed at the index admission was 23%, compared with 73% in 27 patients with a history of bleeding before the index admission (p = 0.001). The rate of recurrence was not influenced by a history of previous uncomplicated ulcer disease or dyspeptic symptoms, the severity of the index bleed, the methods of management of the index bleed, age, use of non-steroidal anti-inflammatory drugs, or long-term treatment with cimetidine.

Review article: maintenance treatment with H2-receptor antagonists for peptic ulcer disease

In recent years a number of different strategies for managing patients with peptic ulcer disease have become available. The present review discusses the relative merits of each form of treatment. Intermittent treatment (whether given in response to symptoms or as a prophylactic regimen prescribed seasonally or at weekends) fails to prevent ulcer recurrence and leaves patients at risk of haemorrhage and perforation. Anti-Helicobacter pylori therapy, although useful in certain circumstances, cannot be recommended for all patients with ulcer disease because of side effects and, in any case, requires further assessment of efficacy. Gastric surgery reduces ulcer recurrence and complications, but operations which have a low incidence of side effects are associated with higher rates of ulcer recurrence, particularly when patients are followed up for more than 10 years. Long-term continuous maintenance treatment with H2-receptor antagonists for 5 or more years effectively prevents ulcer recurrence in the majority of patients and significantly reduces the risk of ulcer complications. In addition, maintenance treatment has proved to be safe and is well tolerated by patients. Maintenance treatment with H2-receptor antagonists is the preferred option for the management of patients with peptic ulcer disease.

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)

Comparison between medical and elective surgical treatment of peptic ulcers

During the last decades we have learnt how to treat chronic peptic ulcer disease both with surgery (mainly vagotomy) and with long term medical treatment (mainly H2-receptor antagonists) with great success and safety. Although much attention has lately been given to 'cytoprotective' agents, it is still too early to regard them as alternatives to acid reducing treatment in the long term management of severe peptic ulcer disease. The importance of campylobacter pylori for long term outcome is today only speculative. Only a few randomized studies have been performed comparing surgical and medical treatment. The hitherto published studies involve small numbers of patients or do not use an optimal dosage of the drug given. Nevertheless for most patients with severe peptic ulcer disease one can conclude that we have both medical and surgical alternatives of comparable efficacy and safety to choose among. The final decision if an elective operation or not should be performed must be based on the preference of the individual patient.

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.

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.

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.

Therapeutic approach to ulcer healing

The healing rate of duodenal ulcers may be accelerated by secretory inhibitors such as histamine H2-receptor antagonists and pirenzepine, by antacids, by protective drugs such as sucralfate and colloidal bismuth, and by antidepressant drugs such as trimipramine. The effect of these drugs on the rate of healing is comparable; they differ with respect to practicability of treatment, incidence and types of side effects, and suitability for long-term administration. Currently, the most versatile and most thoroughly investigated drugs are the histamine H2-receptor antagonists.

Parietal cell vagotomy or cimetidine maintenance therapy for duodenal ulcer? A prospective controlled trial

In a prospective controlled trial 86 duodenal ulcer patients with symptoms severe enough to indicate surgery were randomized to a full-dose cimetidine course followed by maintenance therapy for 1 year or parietal cell vagotomy (PCV). The average follow-up period was 57 months. In the group assigned to medical therapy 62% of the patients were free of symptoms during maintenance therapy, and 12% remained well during the follow-up period. Operation was later performed in 35%, whereas 53% had symptomatic recurrence demanding medical treatment regularly. After PCV no patient died, and there were no serious sequelae. The overall recurrence rate was 17%; after treatment of failures 9% continued to have dyspepsia. Since nearly 3/4 of the patients were free of symptoms after PCV, operation seems to be the method of choice in patients with a severe history and fast recurrence after medical therapy. However, the aged and those at high risk of surgery may benefit from cimetidine maintenance therapy.

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.