Dr. Hammami questions whether the immediate postoperative evaluation before discharge is of any clinical utility and can be omitted. We agree that the 3- to 6-month evaluation is more important because it allows recovery from the immediate postoperative period and therefore may have greater predictive value and is preferred if a single evaluation is done.

We continue to recommend the immediate postoperative evaluation. Although we do not discontinue gastric antisecretory therapy if the postoperative fasting gastrin and secretin test results are normal, these results influence our approach to patients at the 3- to 6-month evaluation. If the patient appears to be disease-free, we stop all gastric antisecretory therapy for 2 weeks before the 3- to 6-month visit. Our recent studies in disease-free patients have shown that, in cured patients, both the basal acid output and maximal acid output decrease rapidly postoperatively [1], and we have found this approach to be safe for these patients. In patients who are not disease-free, we are reluctant to take this approach. Instead, we discontinue H^+/K+ -ATPase inhibitor therapy and begin treatment with histamine-2-receptor antagonists 2 weeks before the 3-to 6-month evaluation.

Histamine-2-receptor antagonists have a shorter duration of action than does the H^+/K+ -ATPase inhibitor [2] and therapy with them can be discontinued during the 3- to 6-month evaluation, permitting acid secretory studies to be done within 2 days without drug interference in most cases. The difference in our approaches to disease-free and non-disease-free patients reflects concern about the possible development of complications from the extreme gastric acid hypersecretion frequently seen in such patients. We could use the latter approach in all patients; however, in some disease-free patients with low gastric acid outputs, possible continued effects of histamine-2-blockers after only a few days without the drug may interfere with the fasting gastrin and secretin test results. Thus, we prefer cessation of the gastric antisecretory drugs 2 weeks before hospitalization.

To facilitate the immediate postoperative evaluation, we do fasting gastrin and secretin studies when the patient is being converted from therapy with continuous intravenous histamine-2-receptor antagonists with oral medications. During this period, drug-induced achlorhydria is rare, and the studies can be done easily without stopping all gastric antisecretory drugs.