New assessment of the completeness of vagotomy and the selection of operation for duodenal ulcer based upon gastric pepsin secretion.

On the basis of the study of gastric pepsin secretion before and after operation for duodenal ulcer, the assessment of the completeness of vagotomy and the selection of operation were attempted. Vagotomy with pyloroplasty that results in a postoperative peak pepsin output (PPO) after insulin stimulation of less than 100 mg tyrosine/hr may well be considered as representing complete vagotomy. In view of the evaluation of ulcer recurrence, this criterion was confirmed to be a more reliable index compared with the criteria based upon gastric acid secretion. Therefore, concerning the selection of operation for duodenal ulcer on the basis of gastric pepsin secretion, we propose the following criteria: Vagotomy with pyloroplasty should be indicated for patients with an insulin-stimulated preoperative PPO less than 500 mg tyrosine/hr; vagotomy with hemigastrectomy for those with 500--1250 mg tyrosine/hr; and distal gastrectomy such as Billroth I operation for those with over 1250 mg tyrosine/hr.