If Mitchell had shown that operative treatment could be effective in compromised patients with perforated ulcers, it seemed reasonable to assume that surgery would be even more successful if used to prevent perforation in patients with uncomplicated ulcer disease. Resectional procedures became commonplace but the results were not as pleasing as expected: since these patients had benign disease, they survived for long enough for the side effects – vomiting and diarrhoea, the ‘dumping syndrome’ and nutritional disturbances - to become a serious drawback. Indeed, a leading gastric surgeon of the time once exclaimed, ‘If anyone wanted to cut out half of my good stomach in order to cure a little ulcer in my duodenum, I would run faster than he!’.⁹ Empirical experimentation with mechanical modifications – led by figures such as Moynihan, Roux and JP Finney, a surgeon of Ulster descent who was the first Resident Surgeon at the celebrated Johns Hopkins Hospital – led to some improvement, but it was parallel advances in the field of gastric physiology which would ultimately revolutionize peptic ulcer treatment.

In the following decade, selective vagotomy, as first performed by Griffith and Harkins, also gained a following, the rationale being that preservation of vagal branches other than those supplying the stomach would reduce the side-effects of the surgery. A prominent Belfast surgeon, Terence Kennedy aptly summarized the dilemma, albeit with a rather quaint analogy: ‘No surgeon wishing to denervate the soleus muscle for intermittent claudication would divide the sciatic nerve in the thigh; yet most surgeons using vagotomy for duodenal ulcer unthinkingly divide the whole of the vagus nerves immediately below the diaphragm, thus dividing all abdominal viscera, except the distal colon, of their para-sympathetic supply.’³ At the same time John Goligher (1912-98), an Ulsterman working in Leeds, suggested that a ‘belt and braces’ approach, using truncal vagotomy to reduce neural acid stimulation combined with antrectomy to reduce hormonal stimuli, was the optimum procedure¹³. Goligher was appointed to the chair of surgery in Leeds in 1955, a post he held until 1978, and, although his major surgical interest was in colon surgery, he nevertheless contributed hugely to the field of gastric surgery by creating an academic environment in which young surgeons could develop expertise as surgeon-investigators.

In that same year, Kennedy was awarded an Honorary MD from Queen's University and was elected to the Council of the Royal College of Surgeons of England. He continued his dynamic partnership with Johnston until his retirement in 1984, true as ever to his lifelong motto, ‘Don't let the grass grow under your feet’, or the Latin equivalent, ‘Carpe Diem’ which was displayed in Wards 15 and 16 until their demolition in 2003³¹. On his last working day he performed a full theatre list as usual, quietly inscribing the word ‘fini’ at the bottom of the final operation report³⁰. He chose never to speak in public again as he firmly believed that medical knowledge became out of date within a day, preferring to spend his last years pursuing his interests in sailing and gardening.

However, by 1994 ulcer surgery truly was almost extinct: Professor Johnston performed only three vagotomies in his last working year. Throughout the 1980s a similar decline in cases of gastric cancer was observed, probably because it similarly was shown to be related to infection with Helicobacter. Epidemiological studies from many Westernised countries showed the incidence of gastric cancer to be declining steadily³⁹. One could be forgiven for supposing that the time had come for gastric surgeons to relinquish their scalpels and seek new occupational horizons. However, just as quickly as ulceration declined, two other diseases became more amenable to surgical treatment, in the wake of the laparoscopic revolution.

The earliest operations for morbid obesity did not involve the stomach at all, but were designed to bypass the small bowel. Their dangerous side effects, including liver failure, renal calculi, and extreme diarrhea, made them too hazardous to gain widespread acceptance. Surgeons then explored the possibility of restricting oral intake by operating on the stomach. Edward Mason of Iowa developed Vertical Banded Gastroplasty in the early 1970s, and though it avoided the mortality associated with intestinal bypass procedures, it was less effective and often caused refractory vomiting⁴⁴. Many other surgeons experimented with different forms of gastric restriction, aided by the co-incidental introduction of surgical stapling into routine operative techniques. Purely restrictive procedures did not produce reliable and symptom free weight loss until the development of the adjustable gastric band, intitally in Sweden⁴⁵. Nowadays, the most common operations performed for morbid obesity are the Roux Y Gastric Bypass and the so-called “lap band”⁴⁶. Thanks in part to the legacy of Terence Kennedy, it is now generally accepted that such innovations must be subjected to careful scrutiny by long-term follow up, and that competing treatments must be subjected to rigorous clinical trials, ensuring that clinicians and patients alike can be sure of their validity. Given the inexorable adoption into Ulster society of patterns of eating and exercise typical of those in North America, the introduction of bariatric surgery into Northern Ireland is unlikely to be far away.