DELAYED ULCER RECURRENCE AFTER GASTRIC RESECTION - A NEW POSTGASTRECTOMY SYNDROME

Recurrent ulceration following gastrectomy for peptic ulcer disease ty pically occurs within the first several years postoperatively. Since 1 990, we have managed 20 patients who had undergone previous gastrectom y for peptic ulcer and developed ulcer recurrence more than 10 years p ostoperatively. Mean age at recurrence was 64 years, and the average t ime from original surgery to recurrent ulceration was 21 years (range, 10-36 years). All patients had undergone vagotomy and antrectomy (17 patients) or subtotal gastrectomy (3 patients). Presenting symptoms in cluded gastric outlet obstruction (70%) and bezoar formation (60%). En doscopic findings in this group of patients included a stenotic gastri c outlet (70%) and marginal ulcerations (80%). Thirteen of 15 patients tested (87%) were Helicobacter pylori positive. Reoperation included partial resection of the gastric pouch and exploration for persistent vagus nerve. Twelve patients underwent Roux-en-Y reconstruction, where as eight patients had Bilroth II reconstruction. Three of the latter g roup also had Braun enteroenterostomy performed. Good to excellent cli nical results were obtained in 80 per cent of patients. The four patie nts with poor outcomes shared the following characteristics: 1) H. pyl ori-positive status, 2) presence of a preoperative bezoar, 3) Roux-en- Y reconstruction. Our current approach is to avoid Roux-en-Y construct ion in favor of Braun enteroenterostomy. Further prospective analysis of long-term postgastrectomy patients is needed to determine whether t his clinical picture represents a new postgastrectomy syndrome.