Postoperative recurrent ulcer.

Figure 2 summarizes my evaluation of most patients with postoperative recurrent ulcers. First, serum gastrin and calcium levels should be determined in all patients. At the initial endoscopy, any silk sutures should be removed, and gastric ulcers biopsied. The presence of gastric ulcers or evidence of delayed gastric emptying should influence the surgical procedure. Ideally, a Congo red test should be performed at the initial endoscopy. The only caveat is that excessive sedation may invalidate the test results. If the initial diagnostic endoscopy does not include a Congo red test and serum gastrin and calcium levels are normal, it is reasonable to proceed with medical management without vagotomy testing. I believe that if medical management fails and operative treatment is planned, all patients should undergo vagotomy testing. If the Congo red test is definitively positive, sham feeding is not necessary. On the other hand, if the Congo red test suggests hyposecretion, I believe that sham feeding is mandatory prior to proceeding with operation. Conversely, sham feeding tests may be falsely negative in postoperative patients. Therefore, many of our patients undergo both Congo red testing and sham feeding prior to reoperation. Finally, if delayed gastric emptying is believed to be part of the clinical syndrome, a radionuclide scan should be performed to assess gastric emptying. It can be either a solid-meal study or an acetanilidoiminodiacetic acid scan, which measures bile reflux as well as determines emptying of bile from the fasted stomach (see introductory article in this issue).