Surgery for acid suppression in the 1990s

Abstract

There has been a global decline in the sequelae of peptic ulcer, measured in terms of hospital admissions, elective operations and absence from work or early retirement due to disability. The number of admissions and elective operations for duodenal ulcer disease had been declining prior to the era of H2 antagonists (Elashoff and Grossman, 1980; Fineberg and Pearlman, 1981; Bloom, 1991). The introduction of HZ antagonists in 1976 merely accelerated this downward trend, and in 1 year following their introduction, the number of elective operations performed fell by 30% (Fineberg and Pearlman, 1981; Wylie et al, 1981). This was followed by a more gradual decline (Bloom, 1991), resulting in a reduction over the next 12 years of more than 90% in the number of elective operations performed (McGuire and Horseley, 1986; Bardhan et al, 1989). The only exception to this trend appears to be in Hong Kong, where there has been no reduction in the number of elective operations performed despite the widespread use of Hz antagonists (Alagaratnam and Wong, 1988). This they attribute to the increasing prevalence of duodenal ulcer disease in Hong Kong where the number of inpatient admissions for peptic ulcer disease has risen by 21% between 1970 and 1980. The indications for surgery have also changed: before HZ antagonists were introduced, 49% of operations were performed for intractability, whereas after their introduction, only 18% of operations are performed for this indication (McConnell et al, 1989) and the majority of operations are now being performed for bleeding or perforation. Fewer patients will come to elective surgery for peptic ulcer disease in the 1990s than in the Hz-antagonist era, since omeprazole can heal up to 100% of Hz-antagonist-resistant ulcers (Tytgat et al, 1987; Bardhan et al, 1991), and omeprazole has been found safe for long-term administration for up to 5 years (McCloy, 1992). It is now recognized that 95% of duodenal ulcers and 80% of gastric ulcers are associated with