Medical Therapy Versus Laparoscopic Surgical Treatment for Ulcer Disease.
The development of low morbidity vagotomy and H2 antagonists in the early 1970s began the debate as to which was the most appropriate treatment for uncomplicated duodenal ulcer. A review of Australian Medicare and Pharmaceutical Benefits Scheme data shows that medical treatment in this country was the preferred option. In the past 12 years, vagotomies have decreased 15-fold while, in the same period, H2 antagonist prescriptions have increased from 0 to 2.5 million per year, doubling in the past 3 years, and currently costs $96 million per year or 6.7% of the country's entire pharmaceutical budget. Similarly, upper gastrointestinal tract endoscopies have increased, costing $15 million per year, doubling in the past 6 years and representing a cost almost equivalent to all other upper gastrointestinal procedures combined. Despite known efficacy and recommendations for use, triple therapy for Heliobacter species is not being used with prescriptions for surface agents actually decreasing to 40,000 per year. A review of the outcome of medical and surgical therapy shows that this expense is not justified; surgery would be more costeffective than medicine at 2 years and safer than medicine after 4 years as a result of complications from failed medical treatment. This margin of benefit is predicted to be greater with laparoscopic vagotomy. Failed medical treatment needs to be redefined by limiting H2 antagonists to a 6-week course. Recurrences or failures are than evaluated endoscopically and those diagnosed with having chronic duoderal ulcers have biopsies taken. Heliobacter pylori positive patients are treated with triple therapy. Failures, recurrences, and originally H pylori negative patients have laparoscopic vagotomy. For such a trial protocol to be evaluated, it requires the long-term use of H2 antagonists to be restricted and laparoscopic vagotomists to document the efficacy of their surgery, including gastric secretion tests.
University Department of Surgery, Austin Hospital, Melbourne, Victoria, Australia
DR
Fletcher