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Background Surgical correction of isolated superficial venous reflux in ulcerated legs reduces short-term recurrence rates but little is known about long-term recurrence. This study aimed to assess the influence of venous reflux pattern and appropriate surgical correction on ulcer healing and long-term recurrence. Methods Patients with chronic leg ulcers were assessed prospectively at a one-stop clinic over 4 years to July 1999. Patients with an ankle: brachial pressure index (ABPI) greater than 0·85, including those with diabetes mellitus and rheumatoid arthritis, were treated with weekly four-layer bandaging in community leg ulcer clinics. Venous duplex studies in all ulcerated legs assessed venous reflux pattern and patients with isolated superficial reflux were offered surgery. Patients were advised to wear class 2 elastic compression stockings after healing and were reviewed at 1, 3, 6 and 9 months, and at 1, 2 and 3 years. Ipsilateral ulceration following healing was designated as recurrence. Results Some 766 ulcerated legs in 689 patients were assessed; 633 legs had an ABPI greater than 0·85. Venous duplex assessment revealed 8 per cent of these legs to have pure deep, 38 per cent pure superficial and 43 per cent a mixed reflux pattern. Ten per cent of legs had no demonstrable reflux. Some 131 of 241 limbs with pure superficial reflux underwent surgery. Healing rates at 12 and 24 weeks for all legs with an ABPI greater than 0·85 were 48 and 68 per cent respectively. Neither venous pattern nor surgery affected ulcer healing rates. Overall 1-, 2- and 3-year recurrence rates for venous ulcers were 25, 31 and 38 per cent respectively. The influence of venous reflux pattern and surgery on ulcer recurrence is summarized in Table. Conclusion Ulcer healing rates are not influenced by venous reflux pattern or surgery. Surgical correction of superficial venous reflux in the presence of chronic leg ulceration reduces long-term ulcer recurrence rates.

A prospective assessment was made of the outcome 4 years after diagnosis of recurrence in a group of 27 patients with documented ulceration after highly selective vagotomy (16 symptomatic recurrence and 11 asymptomatic). In the 16 patients with a previous symptomatic recurrence, eight of the 11 patients with duodenal ulcer underwent a further endoscopy at 4 years and one active ulcer was found. Five patients with previous symptomatic gastric ulcer recurrence have all undergone further surgery. In the 11 patients who originally had an asymptomatic ulcer recurrence (five gastric, six duodenal) no patient has undergone further surgery, although two patients with a recurrent gastric ulcer and two with a recurrent duodenal ulcer subsequently developed symptoms from their ulcer and required H2 receptor blocker therapy. Eight of the 11 originally asymptomatic patients underwent further endoscopy at 4 years and two further duodenal ulcers were found. After highly selective vagotomy, asymptomatic ulcer recurrence occurs frequently and 40 per cent of these patients may develop symptoms.

One hundred patients with duodenal or pyloric/prepyloric ulcer disease were operated with parietal cell vagotomy (PCV) and followed for a minimum of 10 years. At 6 weeks, 1,5 and 10 years postoperatively gastric secretory tests, haematological work-up and clinical examination or telephone interview were performed. There was no operative mortality and the frequency of postoperative sequelae was minimal. The cumulative ulcer recurrence rate was 18 per cent and another 14 per cent had slight to moderate symptoms of epigastric pain without any signs of ulcer. Upper gastrointestinal endoscopy was used to reveal recurrences but was performed only if the patient had symptoms of recurrence. A rise in basal acid secretion and in pentagastrin-stimulated secretion was observed the first year postoperatively, whereas insulin-stimulated peak acid output increased during the first 5 years. We conclude that PCV has a low rate of per- and postoperative complications and an acceptable recurrence rate. Therefore, it seems that PCV is the method of choice in chronic duodenal ulcer disease.

The results of antrectomy for recurrent ulcer after parietal cell vagotomy are reviewed. Eighteen patients underwent precise antrectomy between 6 months and 7 years after their primary operation. Fourteen patients were reconstructed with a gastroduodenostomy and 4 with a gastrojejunostomy. Eighteen patients were available for follow-up of between 18 months and 10 years. One patient (6·25 per cent) developed a recurrent ulcer 1 year after antrectomy. There was no operative mortality. Six patients (33 per cent) had minor complications in the immediate postoperative period, and one (5·5 per cent) had a major complication. According to Visick grading, 75 per cent had good or excellent results and 25 per cent poor results. Antrectomy following parietal cell vagotomy can be achieved with a low operative mortality, a low ulcer recurrence rate and a satisfactorily low incidence of post-gastrectomy problems.