Since the introduction of H2-receptor antagonists, the incidence of ulcer surgery has decreased markedly. Based on the number of patients who underwent ulcer surgery and upper gastrointestinal endoscopy in our hospital, the number of operations for peptic ulcer disease has decreased, although the number of peptic ulcer patients diagnosed
by endoscopy has increased after the introduction of cimetidine (the first H2-receptor antagonist in Japan). The decreasing rate of surgical therapy before and after the administration of H2-receptor antagonists was 49.1%. The number of emergency operations has also decreased among ulcer patients diagnosed by endoscopy although the number of perforated and bleeding ulcer patients has increased. It is also reported that the most common operative procedure for both gastric and duodenal ulcer was distal gastrectomy reconstructed by gastroduodenostomy (Billroth Ⅰ)

Higashiguchi, Ryuichi

Imagawa, Atsushi

Kanaizumi, Toshifumi

Nakano, Hiroshige

Okumura, Toru

Yakura, Mannosuke

Yasuda, Shinji

English

Global Institutional repository of Nara Medical University

(76 ) 奈医誌. (J. Nara Med. Ass.) 41， 76-81，平2THE INCIDENCE OF PEPTIC ULCER SURGERY BEFORE AND AFTER THE INTRODUCTION OF H2-RECEPTOR ANTAGONISTS SHINJI YASUDAへTORUOKUMURA*， RYUICHI HIGASHIGUCHI*， ATSUSHI IMAGAWA*， MANNOSUKE YAKURA*， TOSHIFUMI KANAIZUMI** and HIROSHIGE NAKANO** • Department 01 Surgery， Saiseikai Chuwa Hospital 村 Fi符 tDψartn附 u01 Surgery， Nara Medical University Received January 31， 1990 Summary: Since the introduction of H2-receptor antagonists， the incidence of ulcer surgery has decreased markedly. Based on the number of patients who underwent ulcer surgery and upper gastrointestinal endoscopy in our hospital， the number of operations for peptic ulcer disease has decreased， although the number of peptic ulcer patients diagnosed by endoscopy has increased after the introduction of cimetidine (the first H2-receptor antagonist in ]apan). The decreasing rate of surgical therapy before and after the administration of H2-receptor antagonists was 49.1%. The number of emergency opera-tions has also decreased among ulcer patients diagnosed by endoscopy although the number of perforated and bleeding ulcer patients has increased. It is also reported that the most common operat~ve procedure for both gastric and duodenal ulcer was distal gastrectomy reconstructed by gastroduodenostomy (Bi1roth 1). Index Terms peptic ulcer surgery， H2-receptor antagonists INTRODUCTION Since the introduction of H2-receptor antagonists， a marked decrease in the incidence of elective surgery and no significant decrease in the number of operations for perforated or bleeding ulcer have been reported')-6). In the J apanese literature too， it is reported that the number of operations， which include emergency surgery， has clearly decreased and the incidence of operation for perforated ulcer has not decreased7).8). However， recently the number of patients with peptic ulcer in Japan has gradually increased9). Endoscopic examination in our hospital also showed that the number of ulcer patients has incteased. The aim of this study was to clarify the actual condition of peptic ulcer before and after the introduction of cimetidine and also to discuss the treatment of peptic ulcer disease. PATIENTS AND METHODS From 1977 to 1982， 3，940 patients were diagnosed as having peptic ulcer by upper gastrointestinal endoscopy， and 368 of them underwent ulcer surgery in Saiseikai Chuwa Hospital (323 Abe， Sakurai-city， Nara-prefecture， Japan). The ag田 ofthe patients who underwent endoscopy ranged from 8 to 92 years， with a mean of 49園7years. The male to female ratio was 3. 0: l. Patients who underwent ulcer surg巴rywere not always examined by endoscopy in our hospital. On the other hand， the ages of the The incid巴nceof peptic uIcer surgery before and after the introduction ( 7) of H2-receptor antagonists patients who underwent surgery ranged from 15 to 91 years， with a mean of 44.3 years. The male to female ratio was 4. 2: 1. The trend for the incidence of surgery was calculated based on the number of patients whose diagnosis of ulcer was confirmed by upper gastrointestinal endoscopy from 1977 to 1987 in our hospital. The total number of operations performed between 1977 and 1981 was compared with that between 1983 and 1987. The number of operations in 1982 was exc1uded， because the year 1982 was considered to b巴the year for the turning point of ulcer medication. For statistical evaluation of differences， Student's t test and chi square test were used. Statistical significance was accepted at the 5% level. RESULTS The incidence of patients with peptic ulcer dianosed by upper gastrointestinal endoscopy was almost constant， but increased in those three years (Fig. 1). In 3，940 ulcer patients diagnosed by endoscopy during the study period， 2，617 had gastric ulcer (66.4%)， 828 had duodenal ulc巴r(21.0%) and 495 had gastric and duodenal ulcer (12.6%). However， the number of ulcer operations gradually decreased after the introduction of H2-receptor antagonists (Fig. 2). Of the 368 patiens who underweIlt surgery， 187 had gastric ulcer (50.8%)， 157 had duodenal ulcer (42.7%) and 24 had gastric and duodenal ulcer (11.7%). The total number of operations before and after H2-receptor antagonist therapy was 220 and 112， respectively. The decreasing rate of peptic ulcer operation before and after H2-receptor antagonist therapy was 49.1%. This was statistically significant. During the period b巴foreH2-receptor antagonist therapy， the number of operations for gastric ulcer was 122. On the contrary， the number after H2 receptor antagonist therapy was only 4. This was a statistically significant decrease. The number of operations for duodenal ulcer was much greater than that of gastric ulcer in recent years. The op巴rationrate of peptic ulcer has decreased markedly after the introduction of H2-receptor antagonists (Fig. 3). As far as the complication of peptic ulcer is concerned， bleeding in gastric ulcer and perforation in duodenal ulcer are the most significant. N everth巴less，the rate of complication decreas巴d(No. of Patient5l 1000 E一一一一白向削1 U山lce刷r、p司tient5掴棚叫目円1 ←一一一→白G副 ric山山団eE同一目】目】xDuoden司1U山J1cer 60日十 回一一一回Ga5tri c畠 Duoden司1Ulcer Introduction of cimetidin邑4回目 ↓ / 。/ ι/  //¥¥/ ¥/  。2四十一-0-一一 γ一一~ー 」ー-r-JFO- -d/ JE d 〆x--.: 7_~ J!!"~" 四 ~_x-【』ー -x 山ーーーー骨_::.-，，---- .. 章二二一-;0:一一也ー-JE--ヱi.::---首ー :~-~~-~J;l-日! ?ー同 平1977 78 79 8日 81 82 83 84 85 86 87 (Year) Fig. 1. Number of uIcer patients diagnosed by endoscopy. (78 ) S. Yasuda， etal (Number of Pat i entsl 6日5日4日30 .......t也附'♂、阿 1 ntroduct i onof 陣---_.._--判白1 Pat ients ¥cimetidin陪 x-----xGastr i c U1 cer M ¥↓ ‘片..---問、〆z、白一 〆 問 、 一。一一- 0Duodena 1 U1cer D一一一一回 Gastric息Duodena1U1cer /〆 F 司、z、 ¥ ...T牛戸、、、".，-0，¥..X  、，r ¥ 、ι 一附』20&-三一-x>~. ___Q 、Z、 ¥ \.~//\\n\<，r\白L\、/O---~.\‘阿1日\/、\、 x~ー/~¥ ， 、、0--二二三位ペニーーー-x_ 叫 目、。〆、x~__--x 日1977 78 79 8日号 82 83 84 85 86 87 (Ye日rlFig. 2. N umber of u1c巴rsurgery CX) 4口 A11 U1cer Surgery 30 ___ .--0--- --" 0/ 2口1口口日一ー一一-0白1 U1cer Patients ピ。/¥ /¥Introduction of cimetidine ¥|   0--、¥。 ψ¥ ¥ ¥ 0-ー~眠、¥。一一一九、白1977 78 79 8日 81 82 83 84 85 86 87 (Year 1 Fig. 3. The operation rate of peptic u1cer. among ulcer patients diagnosed by endoscopy. How巴verit has increased among the patients who und巴rwentsurgery (Table 1). The method of operation performed on almost al the peptic ulcers， which include both gastric and duodenal ulcers， was distal gastrectomy reconstructed by gastroduodenostomy or gastrojejunostomy. In the case of perforated ulcer too， distal gastrectomy was usually performed. In 289 of 368 ulcer operations (78.5%)， distal gastrectomy was reconstructed by gastroduodenostomy， and in 63 of 368 (17. 1%) reconstructed by gastrojejunostomy. Only one patient who had reconstruction by gastroduodenos-tomy (0.3%) showed recurrence and thus the patient was reconstructed by gastrojejunostomy. The incidence of peptic ulcer surgery before and after the introduction ( 79) of H，-receptor antagonists DISCUSSION In Western countries， the frequency of peptic u1cer s巴emedto have reached its peak frequency in the middle of the 1950's and duodenal u1cer was more common than gastric u1cer between the First and Second World Wars10). In Japan， the incidence of gastric u1cer was 314.5 per 100，000 inhabitants in 1970 and 500.0 per 100，000 in 1984， while the incidences of duodenal u1c巴rwere 148.3 and 204.5 resp巴ctively9).These results suggest that p巴pticu1cer did not se巴mto have reached its peak in J apan. In our hospital， peptic u1cer showed an increase in frequency in recent years and gastric u1cer was more common than duodenal u1cer throughout the study period. As for u1cer surgery， N agao and associate reported the results of an investigation from 452 hospitals in J apan from 1977 to 198611). According to one of their results， as shown in Table 2， the decreasing rate of surgery was 43.3%. During the period after H2-receptor antagonist therapy， bleeding in gastric u1cer and perforation in duodenal u1cer were also significant complications. In recent years， more than half of th巴operationsin Japan were performed due to bleeding of perforation. It was due to the trend that many peptic u1cer patients， when advised to have surgical treatment， refused on the ground that they would prefer to continue with cimetidine therapy12). Consequ巴nt1y，the indications of operation for peptic u1cer disease after H2-receptor antagonist therapy is indicated only when there is gastric out1et obstruction and perforation. H2-receptor antagonists have made the pepticu1cer operation a less Table 1. The incidence of operation for bleeding and perforated gastric and duodenal ulcer before and after H2-receptor antagonist therapy (H2-RA) Before H2-RA(1977-81) After H2-RA(1983-87) (Among operation/u1cer pati巴nts(%)) Gastric u1cer Bleeding 18 (14.8/2.1) 16 (36.4 * 11.0勺Perforation 2 (1.6/0.24) 2 (1.410.13) Duodenal u1cer Bleeding 7 (8.2/3.2) 2 (3.410.37*) P巴rforation 17 (20.0/7.8) 19 (32.8/3.5*) Total Bleeding 25 (12.1/2.3) 18 (17.6/0.84 ') Perforation 19 (9.2/1.8) 21 (20.6本10.98)Statisticaly significant Table 2. The number of ulcer operation and the incidence of巴mergencyop巴rationbefore and after H2 -receptor antagonist therapy (H2-RA) Before H2-RA(1977-81) After H2-RA(1983-87) Gastric ulcer 24，75 12，74 Bleeding (%) 31.8 53.9* Perforation (%) 7.3 14.2* Duodenal 19，993 12，638 Bleeding (%) 12.9 15.8本Perforation (%) 30.6 47.6* Total 4，768 25，382 Bleeding (%) 23.3 34.9* Perforation (%) 17.7 30.8市Statisticaly significant (80 ) S. Yasuda， etal. frequent and a more difficult one. In controlled trials to compare the valu巴ofH2-receptor antagonist therapy or operation， Anderson et al reported that the cumulative operation rate was more than 50% in patients treated with cimetidine within 24 months after initial treatmentI3)，14) They also advocated that the difference in economic consequences between a more active and a more conservative treatment scheme is so small， though the cimetidine therapy is found to be less expensive than surgery in previous reports同，16) The most important problem in peptic ulcer treatment is the so called “refractory" ulcer. Some controlled trials have been performed and the limit of conservative therapy for peptic ulcer has become clearI7)-19). Appropriate judgment of prognosis of refractory peptic ulcer is now required. The methods of operation for perforated peptic ulcer from the 1940's to 1970's in J apan have been precisely reported by Kaku20). The most common operative procedure for perforated peptic ulcer was extensive gastrectomy， which was responsible for 87.3% of ulcer surgery. Simple closure was only 7. 6% and vagotomy with or without partial gastrectomy was 3.1%， although these procedures were popular in Western countries21). In conclusion， the number of elective and巴mergencyoperations for peptic ulcer has been decreasing after the introductidn of H2-receptor antagonists， although the number of peptic ulcer patiens has been increasing in J apan. This is thought to be the effect of H2-receptor antagonists. However， the problem of refractory ulcer remains. A more precise study of total treatment for peptic ulcer is required. REFERENCES 1) Smith， M.P.: Decline in dundenal ulcer surg巴ry.]AMA. 237: 987-988， 1977. 2) O'Connor， P.C.， Griffiths， K. and Shanks， R.G.: Trends in peptic ulcer related diseases from 1972 to 1980. Eur. ]. Clin. Pharmacol. 24: 435-440， 1983 3) Thomp自on，J.C.: The role of surgery in peptic ulcer. N. Engl. ]. Med. 307: 550-551， 1982 4) Christen自en，A.， Bousfield， R. and Christiansen， J.: Incidence of p巴rforatedand bleeding peptic ulcers before and after the introduction of H2-receptor antagonists. Ann. Surg. 207・4-6，14988. 5) Schein， M.， Saadia， R. and Decker， G.A.G: P巴rforatedp巴pticulc巴rat the ].G. Strijdom Hospital. SAM]. 70: 21-23， 1986. 6) Mckay， A.J. and McArdle， C.S.: Cimetidine and perforat巴dpeptic ulcer. Br.]. Surg. 69・319-320，1982. 7) Taniguch， K.， Oshima， K.， Endo， S.， Konishi， R.， A自ae，M.， Ono， K.， Oka， S.， Fukunaga， H.， Yamamoto， S.， Yamamoto， T.， Kono， N. and Katsumi， M.: Trends of surgical treatment for Gastroduodenal ulcer after introduction of cimetidine. ]pn.]. Gastroenterol. Surg. 18: 1980-1986，1985 Cin ]apanese) 8) Setsu， Y.， Matsubara， Y.， Tamiya， Y.， Takakuwa， K.， Matsuo， H.， Yoshida， M.， Kato， T.， Miura， K.， Nakamura， S. and Muto， T.: Clinical studies on perforated peptic ulcers in Niigata City. ]pn.]. Gastro巴nterol.Surg. 20: 2508-2515， 1987 Cin ]apanese). 9) Watanabe， Y. and Kawai， K.: Epidemiological study on peptic ulcer in ]apan and H2-blockers. Digestive disease seminar 28， Health Publish Co. Inc.， Tokyo， p.7-16，1987 Cin ]apanese). 10) Langman， M.J .S. : What is happening to peptic ulcer? Br. Med. ]. 284: 1063-1064， 1982. 11) N agao， F. and Aoki， T. : Changes in clinical featur巴sof peptic ulcer disease in the surgical practice. Digestive disease seminar 28， H巴althPublishing Co. Inc.， Tokyo， 1987 Cin ]apan巴se).12) Penn， I. : The declining role of the surgeon in the treatment of acid-peptic diseases. Arch. Surg. 115: 134 -135， 1980. 13) Anderson， D.， Amdrup， E.， Sq，rensen， F.H. and Jensen， K.B. : Surgery or cimetidine? 1. Comparison of two plans of treatment: operation or repeated cimetidine. World]. Surg. 7: 372-377， 1983. The incidence of peptic u1cer surgery before and after the introduction ( 81 ) of H2-receptor antagonists 14) Anderson， D.， Amdrup， E.， S.prensen， F.H. and Jensen， K.B. : Surgery or cim巴tidine?11. Comparison of two plans of treatment: operation or cimetidine given as a low maintenance dose. W orld ]. Surg. 7: 378 -384， 1983. 15) Jonsson， B. : The social cost of peptic u1cer in Sweden. Scand.]. Gastro巴nt巴ro1.(Suppl.) 63: 181， 1980. 16) Culyer， A.J. and Maynard， A.K.: Cost-effectiveness of duodenal u1cer treatment. Soc. Sci. Med. 15: 3-8， 1981. 17) Pounder， R.E. : Duodenal u1cers that wi1l not hea1. Gut 25: 697-702， 1984. 18) Bardhan， K.D.: Refractory duodenal u1cer. Gut 25: 711-717， 1984. 19) Quatrini， M.， Basili自co，G. and Bianchi， P.A. : Treatment of 'cimetidine-resistant' chronic duodenal u1cers with ranitidine or cimetidine: a randomized multicentre study. Gut 25: 1113-117， 1984. 20) Kaku， N.: A statistical analysis of perforated Gastric and Duodenal U1cers in Japan during the past 40 years. Kurume Med. ]. 33: 7-4， 1986. 21) Jordan， Jr， G.L.， DeBakey， M.E. and Duncan， Jr， J.M.: Surgical management of perforated peptic u1cer. Ann. Surg. 179: 628-633， 1974. 

THE INCIDENCE OF PEPTIC ULCER SURGERY BEFORE AND AFTER THE INTRODUCTION OF H2-RECEPTOR ANTAGONISTS

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THE INCIDENCE OF PEPTIC ULCER SURGERY BEFORE AND AFTER THE INTRODUCTION OF H2-RECEPTOR ANTAGONISTS

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