Recurrent ulcers

　　Etiology

　　The occurrence of recurrent ulcers is related to the choice of surgical method or improper technical operation during the first surgery, or it may be related to patients with high gastrinemia or taking certain ulcerogenic drugs after surgery.

　　1. Incomplete vagotomy:The recurrence rate of postoperative ulcers after vagotomy varies among different reports, ranging from as low as 1.5% to as high as 30%. Such a large difference indicates that it is related to the surgeon's technique or incomplete cutting. Improving the surgeon's skills and experience is the key to preventing or reducing the recurrence rate of ulcers after vagotomy.

　　2. Inadequate extent of gastric resection:For DU surgery, the resection of the distal stomach should reach more than 75%, if the extent of gastric resection is less than 60%, the postoperative recurrence rate will increase several times. Because the extent of gastric resection is not enough, there are too many residual parietal cells, which keep the gastric acid in a high secretion state.

　　3. Residual gastric antrum mucosa:The gastric antrum mucosa can secrete gastrin. If the choice of surgical method leads to residual gastric antrum mucosa, the G cells secrete a large amount of gastrin, causing ulcer recurrence. If the stripping of the gastric antrum mucosa during Bancrart surgery is not thorough, it can cause recurrent ulcers.

　　4. Jejunum input loop too long or alkaline intestinal fluid diversion:The farther away from the Treitz ligament the jejunum is, the poorer its acid-resistant ability. If the jejunum input loop is too long, it is easy to cause anastomotic jejunal ulcer. In addition, if a lateral anastomosis is performed between the input and output loops or a Rotx-en-Y gastric jejunal anastomosis is performed, due to the diversion of alkaline bile and pancreatic juice, it is also easy to develop anastomotic jejunal ulcer.

　　5. Gastric stasis:After vagotomy or selective vagotomy, due to low gastric tension and concurrent gastric stasis, the gastric wall expands and stimulates the gastric antrum mucosal G cells to continuously release gastrin or directly stimulates the mast cells in the mucosa and submucosa to release histamine. The result is increased gastric acid secretion.

　　6. Others:If the patient has hypergastrinemia before surgery, such as gastrinoma, gastrinoma, multiple endocrine neoplasia type I, hyperparathyroidism, etc., it can lead to increased gastrin levels. In addition, postoperative patients may take ulcerogenic drugs for a long time, such as hormones, aspirin, indomethacin (anti-inflammatory painkillers), etc.

　　The incidence of hemorrhage in recurrent ulcers is 50% to 60%, and the amount of bleeding is often large and fatal. The incidence of perforation is 1% to 5%. More common is chronic penetration, and penetration into the colon can cause a gastric-jejuno-colonic fistula, with an incidence of about 10%. At this time, there are often symptoms such as abdominal pain, diarrhea, dyspepsia, belching, and sometimes fecal smell or mucus in vomit. There is a quick weight loss.

　　The time of onset of recurrent ulcers usually occurs within half a year to several years after surgery, but some patients may occur in the short term after surgery or even after ten or more years. Pain is still the main symptom of recurrent ulcers. The pain is severe but the location is often different from before the operation, which can be in the middle abdomen, left, upper, lower abdomen, back, and rhythmically disappear. The effect of food or antacid is not significant, and there are also reports from abroad that pain only occurs in 40% of cases. It is often accompanied by symptoms such as nausea and vomiting. The cause is mostly due to anastomotic edema, spasm, or obstruction of the pylorus, duodenal bulb outlet, etc.

　　1. Individualized, moderate exercise:According to the age, constitution, condition, and interests of patients with peptic ulcer, appropriate sports projects, exercise intensity, and exercise time should be selected. For patients over middle age, special attention should be paid to the function of their cardiovascular system to ensure it is compatible with the chosen exercise and training methods.

　　2. Gradually increase the amount of exercise step by step:When starting physical exercise, it is advisable to start with a small amount. As the patient's physical health improves, the amount of exercise can gradually increase, and once the appropriate exercise intensity is reached, it should be maintained at this level to continue exercising. It is strictly forbidden to increase the amount of exercise indefinitely or suddenly, in order to avoid adverse reactions.

　　3. Choose a suitable time:Patients with peptic ulcers should not engage in strenuous exercise after meals, nor should they eat immediately after strenuous exercise. Generally, moderate to large amounts of physical exercise should be performed 1 hour after meals, and general walking after meals can help digestion and absorption.

　　4. Whole-body exercise, mutual coordination:For the physical therapy of patients with peptic ulcers, attention should be paid to the combination of whole-body exercise and local exercise to achieve a better rehabilitation and health care effect. Generally, whole-body exercise is the main focus, while appropriate massage therapy should be combined to help improve symptoms, which may have a certain effect on improving the blood circulation of the gastrointestinal tract, promoting the healing of ulcers.

　　5. Perseverance, long-term persistence:Physical therapy has a certain effect on the rehabilitation and health care of peptic ulcers, but it is not an overnight achievement. Only by persisting for a long time can the expected results be achieved. Because the perfection of the body's nervous system, visceral organs, and limb functions, and the enhancement of physical fitness, can be obtained through repeated appropriate amounts of exercise stimulation and strengthening. Usually, the symptoms of peptic ulcers disappear quickly, but the healing of ulcers requires a certain amount of time.

　　1. Gastric juice analysis:If the BAO after ulcer surgery is >5mmol/h and the MAO is >15mmol/h, it indicates the recurrence of ulcers. If BAO increases while MAO does not increase, it means that the parietal cells are in a high secretion state, and there may be causes of hypergastrinemia such as gastrinoma. If MAO increases while BAO does not increase, it means that a large number of parietal cells still remain, and the range of gastric resection is not enough. After vagotomy, if BAO is >2.0mmol/h or MAO is >15mmol/h, it indicates incomplete vagotomy.

　　2. Gastrin measurement:Serum gastrin >500ng/L may indicate a gastrinoma, antral G-cell hyperplasia, or residual gastric antrum mucosa. Further calcium stimulation test or secretin stimulation test should be performed. If serum gastrin >1000ng/L, it can be diagnosed as a gastrinoma.

　　3. Serum calcium determination:To exclude multiple secretory tumors type I syndrome due to hyperparathyroidism.

　　4. Radionuclide scanning:The gastric mucosa can absorb and secrete 99mTc, if there is residual gastric antrum mucosa at the duodenal stump, after intravenous injection of 99mTc, radioactive accumulation will appear in the corresponding area, with a specificity of 100％.

　　5. Conguine red test:Conguine red can be applied locally before or during surgery. If the vagus nerve section is incomplete, the acid secretion of the corresponding gastric mucosa will make the pH≤3, and Conguine red will turn into blue-black.

　　6. Simulated meal test:It is a good method to detect whether the vagus nerve section is complete, ask the patient to chew breakfast and spit it out all together, measure the acid secretion volume of a simulated meal for 1 hour, subcutaneously inject 6μg/kg of pentagastrin, and then measure the peak acid secretion volume (PAO). If SAO/PAO

　　7. Fiberoptic gastroscopy examination:The examination of fiberoptic gastroscopy is of great significance for diagnosis, as it can clearly differentiate between gastritis and ulcers, but ulcers occurring on the jejunal side of the anastomosis after Billroth II surgery or gastrojejunal anastomosis are often not easy to be discovered, and careful observation is required. It is best to use a side-viewing endoscope. Recurrent ulcers after Billroth I surgery are often located on the gastric side of the anastomosis, and the anastomosis is made with non-absorbable sutures, which sometimes can cause suture abscesses and can also produce symptoms similar to ulcers. Sometimes, the center of the anastomotic ulcer observed under gastroscopy is the non-absorbable suture.

　　8. X-ray examination:Barium meal imaging examination of the upper gastrointestinal tract is not as reliable for the diagnosis of recurrent ulcers as for gastric or duodenal ulcers, and it is generally believed to have an accuracy rate of about 50%, therefore, a negative barium meal examination cannot exclude recurrent ulcers. Anastomotic ulcers do not necessarily appear as shadowing on barium meal imaging examination, and sometimes a diagnosis can be made based on the tenderness and irritation of the anastomosis.

　　In the recent period after surgery, barium meal imaging examination often misdiagnoses the normal protuberance or defect of the anastomosis as anastomotic ulcer, which is caused by edema of the anastomosis or the influence of the anastomotic suture, therefore, it is advisable to perform barium meal examination 6 to 8 weeks after surgery.

　　First, therapeutic diet for recurrent ulcers

　　1. Liver depression and qi stagnation type

　　Clinical manifestations: Soreness and distension in the epigastrium, pain radiating to the flanks, slight relief after belching or flatus, severe distension and pain upon anger, belching with acid regurgitation, poor appetite and decreased food intake, thin white tongue coating, wiry pulse.

　　(1) Tangerine Peel Porridge

　　Formula: 1 fresh tangerine peel, 60 grams of glutinous rice.

　　Preparation: Scrape the inside and outside of the tangerine peel clean, soak it in clean water for 1 day, cut it into pieces, place it in a pot, add water, bring to a boil, add glutinous rice, cook the porridge over low heat, and season with scallion, salt, and monosodium glutamate to taste.

　　Effect: Soothe the liver, regulate qi, invigorate the spleen, and open the stomach.

　　Usage: Take 1 dose per day, which can be eaten as breakfast.

　　(2) Finger Citron Pork Stomach Soup

　　Formula: 1 pork stomach (about 500 grams), 15 grams of fresh finger citron, 4 slices of ginger.

　　Preparation: Remove excess fat from the pork stomach, wash it clean, and then blanch it in boiling water to remove the smell. Place the finger citron, ginger, and pork stomach in a pot, add an appropriate amount of water, bring to a boil with high heat, then simmer over low heat for 1 to 2 hours, and season to taste.

　　Effect: Relieve liver depression, regulate qi, harmonize the stomach, and alleviate pain.

　　Usage: Drink the soup and eat the meat, served with meals.

　　(3) Bitter Orange Peel and Green Tangerine Peel Pork Stomach Soup

　　Formula: 1 pork stomach (about 500 grams), 12 grams of bitter orange peel, 6 grams of green tangerine peel, 4 slices of ginger.

　　Preparation: Remove excess fat from the pork stomach, wash it clean, and then blanch it in boiling water to remove the smell. Place the bitter orange peel, green tangerine peel, ginger, and pork stomach in a pot, add an appropriate amount of water, bring to a boil with high heat, then simmer over low heat for 2 hours, and season to taste.

　　Effect: Regulate qi, harmonize the stomach, and alleviate pain.

　　Usage: Drink the soup and eat the meat, served with meals.

　　(4) Malt and Green Tangerine Peel Drink

　　Formula: 30 grams of raw malt, 10 grams of green tangerine peel.

　　Preparation: Boil raw malt and green tangerine peel with an appropriate amount of water, then remove the residue.

　　Effect: Relieve liver depression and regulate qi to alleviate pain.

　　Usage: Take one dose per day, drink as tea.

　　(5) Tangerine Cake Porridge

　　Formula: 3 tangerine cakes, 50 grams of glutinous rice.

　　Preparation: Cut the tangerine cake into pieces and cook it with glutinous rice in a pot.

　　Effect: Harmonizes qi and the stomach.

　　Usage: Take once a day, eat as breakfast.

　　2, Spleen and stomach deficiency-cold type

　　Clinical manifestations include hidden pain in the epigastrium, pain that is relieved by warmth and pressing, worsening with hunger, relieved after eating, prone to occur after being exposed to cold or fatigue, with fullness in the chest and abdomen, yellowish complexion, fatigue, weakness, cold extremities, frequent vomiting of clear saliva, and loose stools. The tongue is pale, with thin, moist fur, the pulse is deep, thin, soft, and weak.

　　(1) Braised Mutton with Carrots

　　Formula: 1000 grams of mutton, 500 grams of carrots.

　　Preparation: Cut the mutton into pieces, and cut the carrots into diamond-shaped pieces. Heat the pot without oil, first fry the carrots for 10 minutes until half-cooked, then remove and set aside. Heat oil in a pan, add 3 spoons of vegetable oil, heat the oil over high heat, add 5 slices of ginger, then add the mutton and stir-fry for 5 minutes, add 3 spoons of yellow wine, and continue to stir-fry until the aroma is released. Add a small amount of fine salt, soy sauce, and a little cold water. Simmer for another 10 minutes, then pour into a clay pot, add the carrots and tangerine peel, add about 3 large bowls of water, bring to a boil over high heat, add 1 spoon of yellow wine, then switch to low heat and simmer for about 2 hours until the mutton is tender and fragrant, then turn off the heat.

　　Effect: Warms the stomach, tonifies deficiency, expels wind and cold.

　　Usage: Eat with meals.

　　(2) Black Date and Glutinous Rice Porridge

　　Formula: 7 black dates, 40 grams of glutinous rice.

　　Preparation: Wash the black dates and glutinous rice, pour them into a small pot, add 2 large bowls of water, boil over high heat, then switch to medium heat and cook for 30 minutes. Add 1 spoon of brown sugar and a little ginger juice, cook for a while, then turn off the heat.

　　Effect: Benefits the middle-jiao and expels cold, warms the spleen and nourishes the stomach.

　　Usage: Eat as breakfast or as a snack.

　　(3) Osmanthus Lotus Seed Pudding

　　Formula: 2 grams of sugar-dipped osmanthus, 60 grams of lotus seeds.

　　Preparation: Soak lotus seeds in boiling water to swell, soak for 1 hour, peel and remove the core. Put the lotus meat into a pot, add an appropriate amount of water, simmer over low heat for about 2 hours until the lotus seeds are soft and the soup is thickened into a porridge. Add sugar and osmanthus, simmer for another 5 minutes, then turn off the heat.

　　Effect: Warms the middle-jiao and disperses cold, benefits the heart and strengthens the spleen, warms the stomach and relieves pain.

　　Usage: Eat as breakfast or as a snack.

　　(4) Mutton Soup

　　Formula: 250 grams of mutton.

　　Preparation: Boil the soup as usual.

　　Effect: Strengthens the spleen and harmonizes the stomach, warms the middle-jiao and disperses cold.

　　Usage: Eat with meals, can be eaten regularly.

　　(5) Tangerine Flower Tea

　　Formula: 3 to 5 grams of tangerine flower, 3 to 5 grams of red tea powder.

　　Preparation: Boil the above two ingredients in boiling water for 10 minutes and drink as tea.

　　Effect: Warms the middle-jiao, regulates qi, harmonizes the stomach, and relieves pain.

　　Usage: Take one dose per day, regardless of time, and take it warm.

　　3, Spleen deficiency and blood stasis type

　　Clinical manifestations include sharp, persistent pain in the epigastrium, fixed pain location, refusal to press, worsening after meals, or accompanied by vomiting blood and black stools. The tongue is purple and dark, or there are ecchymotic spots, the pulse is wiry or涩.

　　(1) Eggshell powder

　　Formula: 6 grams of eggshell powder, 2 grams of salt, 0.6 grams of vitamin C tablet.

　　Preparation: Crush and grind the eggshell (i.e., the shell of an egg) into powder, take 6 grams of eggshell powder, mix it with salt and vitamin C tablets, pour into a bottle for storage. The above is the daily amount.

　　Effect: Harmonizes the stomach and stops bleeding.

　　Usage: Take three times a day, divided into doses, 3 to 5 days as one course of treatment.

　　(2) Hawthorn, Yam, and Carp Soup

　　Formula: Crucian carp 1 piece (about 300 grams), hawthorn 30 grams, huai山药 30 grams.

　　Preparation: Clean the crucian carp, cut it into pieces, heat oil in a pan, stir-fry with ginger slices, add the hawthorn, huai山药, and crucian carp to the pot, add an appropriate amount of water, boil with high heat, then simmer for 1-2 hours with low heat, and season to taste.

　　Effect: Invigorate the spleen and benefit the Qi, activate the blood and remove blood stasis.

　　Usage: Drink the soup and eat the meat, served with meals.

　　(3) Xianhecao Porridge

　　Formula: Xianhecao 20 grams, Sanqi powder 10 grams, glutinous rice 250 grams.

　　Preparation: First, cook the glutinous rice into porridge with an appropriate amount of water. Then add xianhecao and Sanqi powder, and cook for another 20 minutes.

　　Effect: Nourish the blood, strengthen the middle-jiao, and stop bleeding and inflammation.

　　Usage: Take 2 times a day as needed. Take for 5 days as a course.

　　(4) Cuttlefish Porridge

　　Formula: Dried cuttlefish 1 piece, rice 100 grams, mushrooms 50 grams, bamboo shoots a little.

　　Preparation: Remove the bones from the cuttlefish, wash it clean, and cut it into thin strips. Cut the mushrooms and bamboo shoots into thin strips as well. Put clean water, cuttlefish, and cooking wine in a pot, and boil until the fish is soft. Then add rice, mushrooms, and bamboo shoots to cook porridge. Season with salt, monosodium glutamate, and white pepper when the porridge is done.

　　Effect: Nourish and harmonize the blood.

　　Usage: It can be eaten as breakfast and dinner.

　　4. Mixed cold and heat type

　　Clinical manifestations include epigastric pain, preferring warmth and pressure during pain, stuffiness and discomfort, nausea and decreased appetite, dry mouth and bitter taste, constipation, a thick tongue with tooth marks, and a yellow or yellow-white tongue coating. The pulse is wiry or rapid.

　　(1) Potato Honey Paste

　　Formula: Fresh potatoes 1000 grams, an appropriate amount of honey.

　　Preparation: Cut potatoes into strips, mash and squeeze the juice. Put the potato juice in a pot, boil it with high heat first, then simmer it with low heat to thicken, add twice the amount of honey. Boil until thick, stop the fire, wait for it to cool, and then pour it into bottles for storage.

　　Effect: Harmonize the stomach and regulate the middle-jiao.

　　Usage: Take 1 tablespoon twice a day, on an empty stomach.

　　(2) Fresh Cabbage Molasses Juice

　　Formula: Fresh cabbage, an appropriate amount of molasses.

　　Preparation: Wash the cabbage with cold water, mash it, and then squeeze the juice through a sterilized gauze.

　　Effect: Clear heat, relieve pain, and heal ulcers.

　　Usage: Take 1 cup of fresh cabbage juice before breakfast and dinner, add an appropriate amount of molasses, and drink it. Twice a day, 10 days as a course.

　　(3) Ulcer Tea

　　Formula: Tea 250 grams, white sugar 250 grams.

　　Preparation: Add an appropriate amount of clean water to the two ingredients; boil several times, wait for it to cool, sediment, remove the dregs, and store it in a clean container with a lid, stored in a dry place. After 6-12 days, if the color is like old wine, and the surface is like gauze, it can be taken. If there is no surface, it needs to be stored for 7-14 days before it can be drunk.

　　Effect: Harmonize the middle-jiao and dampness, and reduce inflammation and ulcers.

　　Usage: Take 1 tablespoon twice a day, in the morning and evening after steaming the tea.

　　Second, what foods are good for recurrent ulcers:

　　1. Choose a balanced diet with high nutritional value, soft and easy to digest:Such as milk, yogurt, eggs, soy milk, fish, lean meat, etc., processed and cooked to become soft and easy to digest, without irritation to the gastrointestinal tract; at the same time, it supplements sufficient calories, protein, and vitamins; the ratio of the three major nutrients in the semi-liquid stage is about: carbohydrates 60%, protein 15%, fat 25%; and in the liquid stage, carbohydrates 60%, protein 20%, fat 20%.

　　2. Sufficient protein:Protein plays a buffering role in gastric acid, can neutralize gastric acid, but protein can also promote the secretion of gastric acid during digestion in the stomach. Therefore, provide sufficient protein to meet the body's needs, with a daily supply of 1g/kg to promote ulcer repair; if there is anemia, at least 1.5g/kg should be provided.

　　3. No strict limitation of fat is required:Because it can inhibit gastric acid secretion; moderate fat has no stimulation to the gastrointestinal mucosa, but too much can promote the secretion of cholecystokinin, inhibit gastrointestinal motility, and make food in the stomach difficult to enter the duodenum, causing stomach bloating and pain, which can provide 60-70g/d; it is advisable to choose easily digestible and absorbable dairy-like fats, such as milk, butter, egg yolks, cheese, and a moderate amount of vegetable oil.

　　4. Carbohydrates:It has no effect on stimulating gastric acid secretion and does not inhibit gastric acid secretion, and can provide 300-350g per day; choose easily digestible foods such as thick porridge, noodles, wontons, etc.

　　Third, what foods should be avoided for recurrent ulcers

　　1. Avoid foods with excessive mechanical and chemical stimulation:Mechanical stimulation increases mucosal damage, destroying the mucosal barrier, such as coarse grains, celery, chives, winter melon, bamboo shoots, and dried fruits; chemical stimulation increases gastric acid secretion, which is not conducive to ulcer healing, such as coffee, strong tea, strong alcohol, strong meat soup, etc.

　　2. Avoid foods that produce acid easily:Such as sweet potatoes, potatoes, overly sweet pastries, and overly sour foods; easily gas-producing foods, such as raw scallions, raw garlic, raw radishes, garlic oil, onions, etc.;

　　3. Avoid cold and raw foods:Such as large amounts of cold drinks, cold mixed vegetables, etc.;

　　4. Avoid hard foods:Such as preserved pork, ham, sausage, clam meat, etc.;

　　5. Avoid strong seasonings:Such as ground pepper, curry powder, mustard, chili oil, etc.

　　First, the differentiation and treatment of traditional Chinese medicine for herbal medicine

　　1. Disharmony between the liver and stomach:Treatment involves soothing the liver and harmonizing the stomach, using modified Sini Decoction: 9g of Bupleurum chinense, 6g of Gross fruit, 12g of White Peony root, 9g of Tangerine peel, 9g of Prepared pinellia, 9g of Corydalis, 18g of Cuttlefish bone, 5g of Dried甘草.

　　2. Damp-heat syndrome of the spleen and stomach:Treatment involves clearing heat and transforming dampness, using modified Xiaoxiong Decoction: 6g of Coptis (or 9g of Scutellaria), 9g of Dried pinellia, 15g of Poria, 9g of Atractylodes macrocephala, 9g of Tangerine peel, 9g of Moschus, 9g of Bupleurum chinense, 4g of Peach kernel.

　　3. Qi-stagnation and blood stasis syndrome:Treatment involves removing blood stasis and alleviating pain, using modified Shixiao Powder: 9g of Polygonum cillinerve, 9g of Red Peony root, 9g of Corydalis, 9g of Melia toosendan, 15g of Cuttlefish bone, 12g of Chinese arborvitae leaves, 3g of Panax notoginseng (administered twice in water), 9g of Donkey hide glue, 30g of hearth soil, 6g of Dried甘草.

　　4. Deficiency-cold syndrome of the spleen and stomach:Treatment involves warming the stomach and invigorating the spleen, using modified Huangqi Jianzhong Decoction: 15g of prepared Astragalus, 9g of Cinnamon twigs, 12g of White Peony root, 9g of Dried ginger, 9g of Prepared licorice root, four Dried jujubes, 9g of Corydalis, 9g of Golden bellflower, 9g of Evodia, 12g of Atractylodes macrocephala, 15g of Poria.

　　The principles of traditional Chinese medicine can be summarized as follows:

　　1, Invigorating the spleen method:Including invigorating the spleen and qi and warming the middle and invigorating the spleen, common formulas include SiJun Tang, LiZhong Tang, HuangQi JianZhong Tang, etc.

　　2, Soothing the liver and harmonizing the stomach method:Common formulas include SiNi San, Xiaoyao San, etc.

　　3, Clearing the liver and releasing heat method:Common formulas include ZuoJin Wan, Banxia XieXin Decoction, etc.

　　4, Activating blood circulation and removing blood stasis method:Common formulas include XueFu Zhuyu Decoction, GeXia Zhuyu Decoction, etc.

　　5, Nourishing the stomach yin method:Common formulas include YangWei Decoction, LiuWei Di Huang Decoction, etc.

　　6, Coagulation acid control method:Common formulas include GuBei San, XiLian San, and its improved formula 785. Common single herbs include Gancao, Chuanbei, Baiji, Sanqi, and Dahuang, etc.

　　Third, Western medicine treatment

　　1, Drug treatment:First-line treatment with H2 receptor blockers, proton pump inhibitors, somatostatin, and other treatments. Many reports show that about 70% can be cured after 6 to 8 weeks of treatment. Once the medication is stopped, the recurrence rate can reach above 80%. Adding anti-Helicobacter pylori antibiotics such as tetracycline, metronidazole, bismuth preparations, and triple antibiotic therapy can reduce the recurrence rate. However, non-surgical treatment is still only suitable for cases with mild disease, small ulcers, or no surgical conditions.

　　Recurrence of ulcers has many complications, especially massive bleeding that can be fatal, so many advocate surgical treatment.

　　2, Surgical treatment:Surgical treatment should remove the cause of the disease in order to cure. The choice of operation should be individualized, and reasonable choices should be made based on the first operation and the cause of the disease.

　　(1) The first operation is simple gastrojejunostomy: it is advisable to change to subtotal gastrectomy or vagotomy and gastric antrum resection.

　　(2) The first operation is subtotal gastrectomy: if the range of gastric resection is insufficient, vagotomy and gastric re-resection should be the first choice. If the range of gastric resection has reached 75%, and there is no gastric antrum residue, vagotomy and truncal vagotomy should be performed. If there is gastric antrum residue, it must be resected. If the jejunum alimentary limb is too long, it should be corrected and the anastomosis should be reconstructed.

　　(3) The first operation is vagotomy with gastric drainage: it should be changed to vagotomy and gastric antrum resection. If there is difficulty in gastric antrum resection, vagotomy and truncal vagotomy alone can be performed.

　　(4) The first operation is a selective vagotomy: it can be changed to a subtotal gastrectomy or vagotomy and gastric antrum resection.

　　(5) If it is a gastrinoma or hyperparathyroidism, the corresponding surgery should be performed to remove the cause of the disease.