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A modification of the devine operation of pyloric exclusion for duodenal ulcer
A MODIFICATION OF THE DEVINE OPERATION OF
PYLORIC
EXCLUSION
FOR DUODENAL
FREDERIC W. BANCROFT, M.D.,
ULCER*
F.A.C.S.
NEW YORK CITY
W
HEN a duodena1 uIcer is comphcated by gastric retention due to an organic stenosis it is the con-
ity of this procedure presentation. While the operation
FIG. I. Ligation of vessels in gastrohepatic and gastrocoIic omentums, insertion of proximal crushing clamp through transverse mesocolon and distaI cIamp inserted across stomach proximal to reentrant angte.
in this
of gastroenteros-
FIG. 2. Antrum
of stomach after remova of dista1 cIamp. Insertion of temporary rubber band tourniquet to diminish bIeeding. Dotted lines: Schematic Insert shows met,hod of reIationship of vessels. controIIing tourniquet.
sensus of opinion that gastroenterostomy is the operation of choice, but where there is a postpyIoric Iesion without retention gastroenterostomy has not given as satisfactory resuIts as one might wish. This is indicated by the numerous operative procedures that have been devised in place of gastroenterostomy, such as the HorsIey, Judd and Finney pyIoropIasty, and finaIIy the subtota1 gastrectomy. This Iast procedure, in the hands of the genera1 surgeon, presents a mortaIity which precIudes its adoption as the operation of choice. Feeling, therefore, that there is a middle path in the surgica1 treatment of duodena1 uIcer that is more satisfactory than gastroenterostomy and Iess radical than subtota gastrectomy, we present a modification of the Devine operation of antra1 trans-section and exclusion with a PoIya gastrojejunostomy. No claim for originaI* Read before the Southern
is made
tomy is reIativeIy simpIe in textbook description it is, from a technica point of view, not so easy to perform. After the mesocoIon has been perforated and the posterior surface of the stomach drawn into the operative wound and the proxima1 Ioop isoIated, it is difficuIt to feel sure that the Iine of the stoma or the direction of the jejunum is in position to aIIow satisfactory function after replacement of the viscera within the abdomina1 cavity. Moreover, even in the hands of good surgeons, the mortaIity is higher than it is generaIIy believed to be. Devine’ described an operation wherein he cut across the antrum of the stomach 1Devine, H. B. Obsr., 47: 239, 1928.
SurgicaI
223
Association,
Gastric
December
excIusion.
8, 1931.
Surg.
Gynec.
224
American Journal of Surgery
Bancroft-PyIoric
at about the reentrant angIe, inverted the dista1 portion and drew the proxima1 portion through the mesocoIon and per-
FIG. 3. Beginning
dissection of mucosa from muscularis of antrum.
formed a PoIya anastomosis with the proxima1 Ioop of jejunum. TheoreticaIIy this operation has the foIIowing advantages over subtota1 gastrectomy: (I) It is unnecessary to dissect the antrum and pyIorus free from the gastrohepatic and gastrocoIic omenturns. (2) It obviates the necessity of dissecting ulcers Iocated on the posterior surfaces of the duodenum from the head of the pancreas. (3) Where the uIcer is situated near the papiIIa of Vater cIosure of the duodenum stump has presented marked technica dificuIties; these diffIcuIties are obviated by this operation. It has the foIIowing theoretica disadvantages: (I) There is Ieft a gastric mucous membrane in the distal portion of the stomach which may continue to bathe the uIcer with its secretion and thereby deIay healing. (2) It is generaIIy considered an inadvisabIe surgica1 procedure to Ieave a bIind pouch anywhere in the gastrointestina1 course. In dogs where this operation has been done experi-
ExcIusion
MAY. 193~
mentaIIy the antra1 pouch, whiIe contracted, contains a greenish detritus which wouId seem to be obnoxious.
FIG. 4. CompIetion of dissection of mucosa. CIamps apphed before insertion of inverting mucosal suture.
As a means of correcting the aforementioned disadvantages of the Devine operation, Dr. Lewis Gregory CoIe suggested that this operation couId be improved by coning out the mucous membrane of the antrum as far as the pyIorus and then inverting the mucosa and muscular coats. The detaiIs of this procedure are to be described in the Iatter part of this articIe. At the beginning of my connection with the Fifth Avenue HospitaI, Dr. CoIe, chief of the radioIogica1 department, Dr. Tenney, chief of the medica department, and myseIf, as chief of the surgica1 department, came to a working agreement that no case of duodena1 uIcer should be referred for operation unIess two out of the three decided that operation was advisabIe. It was our opinion that no case shouId become surgica1 unIess it had had a proIonged and satisfactory course of medica treatment or unIess there was radioIogica1 evidence that perforation might ensue unIess operative pro-
NEW SERIES VOL. XVI, No. 2
Bancroft-PyIoric
cedure was carried out. As a resuh of this agreement the surgica1 department has not had a great number of cases referred for operation: In addition, the cases that have been referred are obviousIy medica faiIures and therefore shouId not be grouped on equa1 terms in anaIyzing fohow-up resuhs with earIy submucous uIcers, duodenitis and simiIar conditions which are incIuded in any anaIysis of medica treatment of ulcer. 14 consecutive I propose to present cases of duodena1 uIcer subjected to the modified Devine operation of pyIoric excIusion. I reaIize that this series is smaI1 and that a foIIow-up of three and one-half years, which have eIapsed in the oIdest cases, is not sufficient for a compIete endresuIt analysis; but this is a carefully seIected series of cases that have defied medica treatment and wherein it has been the consensus of opinion of the attending physician, surgeon and radiologist that operative procedure is indicated. In an earIier discussion with Dr. CoIe about the end resuIts of the patients subjected to operation he made the statement that no surgeon couId give a proper evaIuation of his own operation any more than a father couId properIy evaIuate his own son. I then made the suggestion that I wouId send for a11 cases operated upon and Ieave the evaIuation of the foIIow-up to Dr. CoIe and would stand by his concIusions. As Dr. CoIe has been opposed in genera1 to operative procedure in duodena1 uIcers it would seem that the study of end resuIts is fairly accurate. DESCRIPTION
OF
OPERATION
As the iIIustrations show cIearIy the steps of the operative procedure onIy the important points wiI1 be mentioned. We have found that the incision described by Tate Mason gives the best exposure of the stomach and appendix. After opening the peritoneum and inspecting the pathoIogy of the stomach and duodenum the vessels of the Iesser curvature are Iigated just proxima1 to the reentrant angIe over
Exclusion
American
Journal of Surgery
225
an area sufficient to insert two gastric cIamps. A simiIar procedure is carried out on the greater curvature opposite
FIG. 3. CompIetion
of inverting mucosal stitch. Antrum is then closed with two to three purse-string sutures, final one being an inverting peritoneal suture.
the site chosen on the Iesser curvature. Next the transverse coIon is drawn up into the wound and its mesocoIon is perforated in the avascuIar area. A Peyer crushing cIamp is inserted through this perforation so that the bIades pass one on each surface of the stomach. A second non-crushing cIamp is appIied dista1 to the Peyer cIamp but is inserted through the perforation of the gastrocohc omentum and not through mesocoIon. (See Fig. I.) The stomach is cut across cIose to the crushing cIamp with either cautery or carboIized knife. The Peyer cIamp encIosing the proxima1 portion of the stomach is wrapped in a steriIe string pad, to protect the wound from contamination. AIIis clamps are appIied to the cut end of the dista1 portion, the dista1 gastric cIamp is removed and the lumen of the antrum exposed. (Fig. 2.) At this stage a finger may be passed through the pyIorus and the Iumen of the duodenum paIpated
226
American Journal of Surgery
Bancroft-PyIoric
from within for uIcer. I have found that if a rubber band is appIied as a temporary tourniquet about the pyIorus, as shown in
Exclusion
MAY, 1932
purse-string sutures and a fina inverting peritonea1 suture. Figures 6 and 7 show the Iatter steps of
FIG. 6.
FIG.
7.
FIG. 6. ProximaI portion of stomach drawn through transverse mesocolon and beginning anastomosis with proximal portion of jejunum. Lesser curvature is united to proxima1 portion of jejunum shortIy after its emergence from fossa of Treitz. FIG. 7. Continuation of anastomosis after portion of stomach which has been heId by bite of crushing clamp has been excised.
Figure 3, it diminishes the bIeeding whiIe the mucosa is being excised. The dissection of the mucosa1 Iayer is carried out as shown in Figures 4 and 5. When the prepyIoric area is approached a Kocher cIamp is appIied and the dissected mucosa excised. The pyloric mucosa is cIosed with an inverting suture. The temporary tourniquet is then removed, bIeeding points are cIamped and ligated, and the antrum cIosed with two or three
the anastomosis. The jejunum is isoIated cIose to where it presents from the fossa of Treitz and is anastomosed side to end with the stomach so that the proxima1 portion of the jejunum, about 4 to 7 cm. from the fossa of Treitz, is attached to the Iesser curvature. The anastomosis is made without cIamps after the excision of the portion of the stomach within the bite of the Peyer crushing cIamp. Care is taken to Iigate a11 bIeeding points. Three Iayers of sutures
NEW SERIES VOL. XVI, No.
2
Bancroft-Pyloric
ExcIusion
American Journal of Surgery
227
are appIied anteriorIy and posteriorIy, particular care being used to unite the mucous membrane. Figures 8 and g show
PostoperativeIy ff uids are administered either subcutaneousIy or intravenousIy the day of operation and the first two days
FIL. 8. Appearance of anastomosis after its completion, showing mesocolon united to stomach I to z cm. proximat to anastomosis.
F~ti. 0. Appearance of stomach and inverted antrum at completion of operation. A, IJlcer. 13, Inverted antrum. c, Schematic sketch of rctrocoiic gastrojcjunostomy.
the operative procedure compIete. FoIIowup roentgenographs show that with the anastomosis made as described above there is a free exit of the barium mea1 from the dista1 Ioop and no pocketing in the proxima1 loop. (Fig. IO.) Success or faiIure of any operative procedure is IargeIy dependent upon the ante-operative and postoperative therapy; therefore, the routine procedures are shown in TabIes I and II. In the ante-operative therapy particuIar stress is Iaid upon the subcutaneous administration of fluid; in addition a gastric Iavage the morning of operation is given in order to have a clean surface for anastomosis. As the operation is frequentIy associated with an appendectomy and may take an hour and a half, the choice of anesthesia is important. NearIy a11 the cases have been done under ethylene and recentIy under avertin and ethyIene. We have no objection to spina anesthesia but fee1 that our results with ethyIene have justified its continuance as the anesthesia of choice.
postoperative. It is our contention that fluids shouId be administered before there is definite indication, because once that time arrives it is often too late. The use of the Levin tube inserted through the nares immediateIy after the
FIG. IO. Postoperative
gastric radiograph. A, Beginning jejunum at fossa of Treitz. B, Stoma.
patient has regained consciousness is a life-saving measure. The nurse is instructed to use a 50 C.C. syringe and to irrigate and suck out the stomach every two hours
228
American Journal of Surgery
Bancroft-PyIoric
Exchsion
._
_
_
_
._
-i
_ ,
-
_
.I
-..
NEW SERIES VOL. XVI, No. 1
Bancroft---PyIoric
day and night for the first forty-eight hours postoperative. The suction removes bIood cIot and gas and prevents postoperative vomiting and diIatation. When the washings return reIativeIy cIear in two successive irrigations the tube is removed, and if the operator is not certain
Exclusion
American
Journalof
Surgerv
229
a jejunostomy was performed, the patient was fed through this and made a reIativeIy sIow recovery. A further description of her case wil1 be given under Iate resuks. There were two wound infections. Late Complications. Two who had wound infections,
of the series, showed inci-
TABLE II POSTOPERATIVEROUTlNE Prrop. FIuids by mouth.
Forced
’ Day of op. None
i 1st day postop. Aq. I oz.
2nd day postop.
3rd day postop.
Aq. I oz
I1q. 35 h. 1pep. mk: I oz. ! c:i .2npl’. 2 oz . i alternating ) zdternating , ~q. 2 h. q. 2 h. Fluids by rectum.
None
$ oz.
3 oz.
i q. 3 h. q* 3 h. Hypodermoclysis.
-__
Lavage.................................. -~--
Enemas
Once
-__
Twice
__._
and coIon irrigations..
.
.
OF
CASES
Immediate Postoperative Complications. There was no death in this series. There was one postoperative pneumonitis with an eIevation of temperature for four days, with x-ray confirmation; one bronchitis, with suppurative sputum and eIevation of temperature for three days, x-ray evidence showing peribronchia1 infiItration. In the Iast patient operated upon under this procedure the operation was compIicated by an appendectomy and choIecvstectomy for numerous gaIIstones. On the eighth day the patient deveIoped a biIiary fistuIa compIicated with a right lower Iobe pneumonia. The biIiary fistuIa as a compIication does not seem attributable to the gastric operation. One patient had persistent vomiting for five days with apparentIy an obstruction of the dista1 Ioop of the stoma. Under IocaI anesthesia
Twice
q. 2 h. ~q. 2 h.
I . / Enema twice ’ None
of the condition of the stomach it is reinserted six hours Iater and suction and irrigation applied to be sure there is no dilatation. TabIe II gives the detaik of the postoperative therapy in this series. REVIEW
Once
/Colonic
3 oz.
q. 3 h. As indicated As indicated
I / Colonic
3 oz. q. 3 Il.
i “o”“_____ ~None Colonic
siona1 hernia on return to the cIinic at the end of a year.
foIIow-up
One patient died a year and a half postoperativeI?, of intestina1 obstruction. This is the patient upon whom a jejunostomy was done foIlowing the operative procedure. She continued to have gastric and intestinal symptoms folIowing the original operation and was treated by a very competent gastroenteroIogist in Chicago. A vear and a half later, whiIe I was out of the &y, she returned with signs of intestina1 obstruction and was operated upon by one of my associates. She had symptoms of persistent vomiting and pain in the epigastrium. At operation he found that the smal1 intestines were diIatec1 and congested. A jejunostomy was performed. She recovered sIowIy and was abIe to Ieave the hospita1, aIthough not completely weI1, and returned a month later with a second attack of vomiting and obstruction. At this time I operated upon her and performed a short circuiting operation between a distended and contracted Ioop. She deveIoped further obstructive symptoms and peritonitis, and died. At postmortem examination in addition to a diffuse peritonitis it was found that there
230
American Journal of Surgery
Bancroft-PyIoric
was a herniation of a Ioop of jejunum just dista1 to the anastomosis through the mesocoIon posterior to the stomach into the Iesser sac. In reviewing this case with our follow-up, x-rays and history of her symptomotoIogy, it seems evident that she deveIoped this herniation shortIy after her first operation and it had persisted in this position unti1 her exodus.
At the time of the origina operation the mesocoIon was sutured to the anterior surface of the stomach but not to the posterior. It has been to the writer an object Iesson of the necessity of suturing the mesocoIon to the posterior as we11 as the anterior gastric surface in performing an anastomosis. Follow-up. As shown in TabIe I, IO cases are reported as exceIIent, 2 as fair and one as poor, the patient having died of intestina1 obstruction. One has been operated upon too recentIy to warrant any concIusions. TweIve of the 14 wouId recommend operation to any friend of
MAY, ,932
ExcIusion
theirs. Eight eat everything; 4 are we11 if they omit certain articIes of food, such as fried foods and food with much residue. If they depart from their diet they have some gas and distress after eating, but nothing compared to the symptoms they suffered before operation. CONCLUSIONS
The modification of the Devine operation in a smaI1 series of cases has proved to have a Iow enough mortaIity and satisfactory enough end resuIts to warrant its use in postpyIoric uIcers where the uIcers are adherent to the pancreas or in the neighborhood of the papiIIa of Vater. Its use is advocated in patients who have defied medical care and in those where there is no marked gastric retention. I wish to express my thanks to Dr. CharIes W. Lester for having tabuIated the resuIts and to Dr. Lewis Gregory CoIe for much vaIuabIe advice.
PYLORIC
EXCLUSION
FOR DUODENAL
FREDERIC W. BANCROFT, M.D.,
ULCER*
F.A.C.S.
NEW YORK CITY
W
HEN a duodena1 uIcer is comphcated by gastric retention due to an organic stenosis it is the con-
ity of this procedure presentation. While the operation
FIG. I. Ligation of vessels in gastrohepatic and gastrocoIic omentums, insertion of proximal crushing clamp through transverse mesocolon and distaI cIamp inserted across stomach proximal to reentrant angte.
in this
of gastroenteros-
FIG. 2. Antrum
of stomach after remova of dista1 cIamp. Insertion of temporary rubber band tourniquet to diminish bIeeding. Dotted lines: Schematic Insert shows met,hod of reIationship of vessels. controIIing tourniquet.
sensus of opinion that gastroenterostomy is the operation of choice, but where there is a postpyIoric Iesion without retention gastroenterostomy has not given as satisfactory resuIts as one might wish. This is indicated by the numerous operative procedures that have been devised in place of gastroenterostomy, such as the HorsIey, Judd and Finney pyIoropIasty, and finaIIy the subtota1 gastrectomy. This Iast procedure, in the hands of the genera1 surgeon, presents a mortaIity which precIudes its adoption as the operation of choice. Feeling, therefore, that there is a middle path in the surgica1 treatment of duodena1 uIcer that is more satisfactory than gastroenterostomy and Iess radical than subtota gastrectomy, we present a modification of the Devine operation of antra1 trans-section and exclusion with a PoIya gastrojejunostomy. No claim for originaI* Read before the Southern
is made
tomy is reIativeIy simpIe in textbook description it is, from a technica point of view, not so easy to perform. After the mesocoIon has been perforated and the posterior surface of the stomach drawn into the operative wound and the proxima1 Ioop isoIated, it is difficuIt to feel sure that the Iine of the stoma or the direction of the jejunum is in position to aIIow satisfactory function after replacement of the viscera within the abdomina1 cavity. Moreover, even in the hands of good surgeons, the mortaIity is higher than it is generaIIy believed to be. Devine’ described an operation wherein he cut across the antrum of the stomach 1Devine, H. B. Obsr., 47: 239, 1928.
SurgicaI
223
Association,
Gastric
December
excIusion.
8, 1931.
Surg.
Gynec.
224
American Journal of Surgery
Bancroft-PyIoric
at about the reentrant angIe, inverted the dista1 portion and drew the proxima1 portion through the mesocoIon and per-
FIG. 3. Beginning
dissection of mucosa from muscularis of antrum.
formed a PoIya anastomosis with the proxima1 Ioop of jejunum. TheoreticaIIy this operation has the foIIowing advantages over subtota1 gastrectomy: (I) It is unnecessary to dissect the antrum and pyIorus free from the gastrohepatic and gastrocoIic omenturns. (2) It obviates the necessity of dissecting ulcers Iocated on the posterior surfaces of the duodenum from the head of the pancreas. (3) Where the uIcer is situated near the papiIIa of Vater cIosure of the duodenum stump has presented marked technica dificuIties; these diffIcuIties are obviated by this operation. It has the foIIowing theoretica disadvantages: (I) There is Ieft a gastric mucous membrane in the distal portion of the stomach which may continue to bathe the uIcer with its secretion and thereby deIay healing. (2) It is generaIIy considered an inadvisabIe surgica1 procedure to Ieave a bIind pouch anywhere in the gastrointestina1 course. In dogs where this operation has been done experi-
ExcIusion
MAY. 193~
mentaIIy the antra1 pouch, whiIe contracted, contains a greenish detritus which wouId seem to be obnoxious.
FIG. 4. CompIetion of dissection of mucosa. CIamps apphed before insertion of inverting mucosal suture.
As a means of correcting the aforementioned disadvantages of the Devine operation, Dr. Lewis Gregory CoIe suggested that this operation couId be improved by coning out the mucous membrane of the antrum as far as the pyIorus and then inverting the mucosa and muscular coats. The detaiIs of this procedure are to be described in the Iatter part of this articIe. At the beginning of my connection with the Fifth Avenue HospitaI, Dr. CoIe, chief of the radioIogica1 department, Dr. Tenney, chief of the medica department, and myseIf, as chief of the surgica1 department, came to a working agreement that no case of duodena1 uIcer should be referred for operation unIess two out of the three decided that operation was advisabIe. It was our opinion that no case shouId become surgica1 unIess it had had a proIonged and satisfactory course of medica treatment or unIess there was radioIogica1 evidence that perforation might ensue unIess operative pro-
NEW SERIES VOL. XVI, No. 2
Bancroft-PyIoric
cedure was carried out. As a resuh of this agreement the surgica1 department has not had a great number of cases referred for operation: In addition, the cases that have been referred are obviousIy medica faiIures and therefore shouId not be grouped on equa1 terms in anaIyzing fohow-up resuhs with earIy submucous uIcers, duodenitis and simiIar conditions which are incIuded in any anaIysis of medica treatment of ulcer. 14 consecutive I propose to present cases of duodena1 uIcer subjected to the modified Devine operation of pyIoric excIusion. I reaIize that this series is smaI1 and that a foIIow-up of three and one-half years, which have eIapsed in the oIdest cases, is not sufficient for a compIete endresuIt analysis; but this is a carefully seIected series of cases that have defied medica treatment and wherein it has been the consensus of opinion of the attending physician, surgeon and radiologist that operative procedure is indicated. In an earIier discussion with Dr. CoIe about the end resuIts of the patients subjected to operation he made the statement that no surgeon couId give a proper evaIuation of his own operation any more than a father couId properIy evaIuate his own son. I then made the suggestion that I wouId send for a11 cases operated upon and Ieave the evaIuation of the foIIow-up to Dr. CoIe and would stand by his concIusions. As Dr. CoIe has been opposed in genera1 to operative procedure in duodena1 uIcers it would seem that the study of end resuIts is fairly accurate. DESCRIPTION
OF
OPERATION
As the iIIustrations show cIearIy the steps of the operative procedure onIy the important points wiI1 be mentioned. We have found that the incision described by Tate Mason gives the best exposure of the stomach and appendix. After opening the peritoneum and inspecting the pathoIogy of the stomach and duodenum the vessels of the Iesser curvature are Iigated just proxima1 to the reentrant angIe over
Exclusion
American
Journal of Surgery
225
an area sufficient to insert two gastric cIamps. A simiIar procedure is carried out on the greater curvature opposite
FIG. 3. CompIetion
of inverting mucosal stitch. Antrum is then closed with two to three purse-string sutures, final one being an inverting peritoneal suture.
the site chosen on the Iesser curvature. Next the transverse coIon is drawn up into the wound and its mesocoIon is perforated in the avascuIar area. A Peyer crushing cIamp is inserted through this perforation so that the bIades pass one on each surface of the stomach. A second non-crushing cIamp is appIied dista1 to the Peyer cIamp but is inserted through the perforation of the gastrocohc omentum and not through mesocoIon. (See Fig. I.) The stomach is cut across cIose to the crushing cIamp with either cautery or carboIized knife. The Peyer cIamp encIosing the proxima1 portion of the stomach is wrapped in a steriIe string pad, to protect the wound from contamination. AIIis clamps are appIied to the cut end of the dista1 portion, the dista1 gastric cIamp is removed and the lumen of the antrum exposed. (Fig. 2.) At this stage a finger may be passed through the pyIorus and the Iumen of the duodenum paIpated
226
American Journal of Surgery
Bancroft-PyIoric
from within for uIcer. I have found that if a rubber band is appIied as a temporary tourniquet about the pyIorus, as shown in
Exclusion
MAY, 1932
purse-string sutures and a fina inverting peritonea1 suture. Figures 6 and 7 show the Iatter steps of
FIG. 6.
FIG.
7.
FIG. 6. ProximaI portion of stomach drawn through transverse mesocolon and beginning anastomosis with proximal portion of jejunum. Lesser curvature is united to proxima1 portion of jejunum shortIy after its emergence from fossa of Treitz. FIG. 7. Continuation of anastomosis after portion of stomach which has been heId by bite of crushing clamp has been excised.
Figure 3, it diminishes the bIeeding whiIe the mucosa is being excised. The dissection of the mucosa1 Iayer is carried out as shown in Figures 4 and 5. When the prepyIoric area is approached a Kocher cIamp is appIied and the dissected mucosa excised. The pyloric mucosa is cIosed with an inverting suture. The temporary tourniquet is then removed, bIeeding points are cIamped and ligated, and the antrum cIosed with two or three
the anastomosis. The jejunum is isoIated cIose to where it presents from the fossa of Treitz and is anastomosed side to end with the stomach so that the proxima1 portion of the jejunum, about 4 to 7 cm. from the fossa of Treitz, is attached to the Iesser curvature. The anastomosis is made without cIamps after the excision of the portion of the stomach within the bite of the Peyer crushing cIamp. Care is taken to Iigate a11 bIeeding points. Three Iayers of sutures
NEW SERIES VOL. XVI, No.
2
Bancroft-Pyloric
ExcIusion
American Journal of Surgery
227
are appIied anteriorIy and posteriorIy, particular care being used to unite the mucous membrane. Figures 8 and g show
PostoperativeIy ff uids are administered either subcutaneousIy or intravenousIy the day of operation and the first two days
FIL. 8. Appearance of anastomosis after its completion, showing mesocolon united to stomach I to z cm. proximat to anastomosis.
F~ti. 0. Appearance of stomach and inverted antrum at completion of operation. A, IJlcer. 13, Inverted antrum. c, Schematic sketch of rctrocoiic gastrojcjunostomy.
the operative procedure compIete. FoIIowup roentgenographs show that with the anastomosis made as described above there is a free exit of the barium mea1 from the dista1 Ioop and no pocketing in the proxima1 loop. (Fig. IO.) Success or faiIure of any operative procedure is IargeIy dependent upon the ante-operative and postoperative therapy; therefore, the routine procedures are shown in TabIes I and II. In the ante-operative therapy particuIar stress is Iaid upon the subcutaneous administration of fluid; in addition a gastric Iavage the morning of operation is given in order to have a clean surface for anastomosis. As the operation is frequentIy associated with an appendectomy and may take an hour and a half, the choice of anesthesia is important. NearIy a11 the cases have been done under ethylene and recentIy under avertin and ethyIene. We have no objection to spina anesthesia but fee1 that our results with ethyIene have justified its continuance as the anesthesia of choice.
postoperative. It is our contention that fluids shouId be administered before there is definite indication, because once that time arrives it is often too late. The use of the Levin tube inserted through the nares immediateIy after the
FIG. IO. Postoperative
gastric radiograph. A, Beginning jejunum at fossa of Treitz. B, Stoma.
patient has regained consciousness is a life-saving measure. The nurse is instructed to use a 50 C.C. syringe and to irrigate and suck out the stomach every two hours
228
American Journal of Surgery
Bancroft-PyIoric
Exchsion
._
_
_
_
._
-i
_ ,
-
_
.I
-..
NEW SERIES VOL. XVI, No. 1
Bancroft---PyIoric
day and night for the first forty-eight hours postoperative. The suction removes bIood cIot and gas and prevents postoperative vomiting and diIatation. When the washings return reIativeIy cIear in two successive irrigations the tube is removed, and if the operator is not certain
Exclusion
American
Journalof
Surgerv
229
a jejunostomy was performed, the patient was fed through this and made a reIativeIy sIow recovery. A further description of her case wil1 be given under Iate resuks. There were two wound infections. Late Complications. Two who had wound infections,
of the series, showed inci-
TABLE II POSTOPERATIVEROUTlNE Prrop. FIuids by mouth.
Forced
’ Day of op. None
i 1st day postop. Aq. I oz.
2nd day postop.
3rd day postop.
Aq. I oz
I1q. 35 h. 1pep. mk: I oz. ! c:i .2npl’. 2 oz . i alternating ) zdternating , ~q. 2 h. q. 2 h. Fluids by rectum.
None
$ oz.
3 oz.
i q. 3 h. q* 3 h. Hypodermoclysis.
-__
Lavage.................................. -~--
Enemas
Once
-__
Twice
__._
and coIon irrigations..
.
.
OF
CASES
Immediate Postoperative Complications. There was no death in this series. There was one postoperative pneumonitis with an eIevation of temperature for four days, with x-ray confirmation; one bronchitis, with suppurative sputum and eIevation of temperature for three days, x-ray evidence showing peribronchia1 infiItration. In the Iast patient operated upon under this procedure the operation was compIicated by an appendectomy and choIecvstectomy for numerous gaIIstones. On the eighth day the patient deveIoped a biIiary fistuIa compIicated with a right lower Iobe pneumonia. The biIiary fistuIa as a compIication does not seem attributable to the gastric operation. One patient had persistent vomiting for five days with apparentIy an obstruction of the dista1 Ioop of the stoma. Under IocaI anesthesia
Twice
q. 2 h. ~q. 2 h.
I . / Enema twice ’ None
of the condition of the stomach it is reinserted six hours Iater and suction and irrigation applied to be sure there is no dilatation. TabIe II gives the detaik of the postoperative therapy in this series. REVIEW
Once
/Colonic
3 oz.
q. 3 h. As indicated As indicated
I / Colonic
3 oz. q. 3 Il.
i “o”“_____ ~None Colonic
siona1 hernia on return to the cIinic at the end of a year.
foIIow-up
One patient died a year and a half postoperativeI?, of intestina1 obstruction. This is the patient upon whom a jejunostomy was done foIlowing the operative procedure. She continued to have gastric and intestinal symptoms folIowing the original operation and was treated by a very competent gastroenteroIogist in Chicago. A vear and a half later, whiIe I was out of the &y, she returned with signs of intestina1 obstruction and was operated upon by one of my associates. She had symptoms of persistent vomiting and pain in the epigastrium. At operation he found that the smal1 intestines were diIatec1 and congested. A jejunostomy was performed. She recovered sIowIy and was abIe to Ieave the hospita1, aIthough not completely weI1, and returned a month later with a second attack of vomiting and obstruction. At this time I operated upon her and performed a short circuiting operation between a distended and contracted Ioop. She deveIoped further obstructive symptoms and peritonitis, and died. At postmortem examination in addition to a diffuse peritonitis it was found that there
230
American Journal of Surgery
Bancroft-PyIoric
was a herniation of a Ioop of jejunum just dista1 to the anastomosis through the mesocoIon posterior to the stomach into the Iesser sac. In reviewing this case with our follow-up, x-rays and history of her symptomotoIogy, it seems evident that she deveIoped this herniation shortIy after her first operation and it had persisted in this position unti1 her exodus.
At the time of the origina operation the mesocoIon was sutured to the anterior surface of the stomach but not to the posterior. It has been to the writer an object Iesson of the necessity of suturing the mesocoIon to the posterior as we11 as the anterior gastric surface in performing an anastomosis. Follow-up. As shown in TabIe I, IO cases are reported as exceIIent, 2 as fair and one as poor, the patient having died of intestina1 obstruction. One has been operated upon too recentIy to warrant any concIusions. TweIve of the 14 wouId recommend operation to any friend of
MAY, ,932
ExcIusion
theirs. Eight eat everything; 4 are we11 if they omit certain articIes of food, such as fried foods and food with much residue. If they depart from their diet they have some gas and distress after eating, but nothing compared to the symptoms they suffered before operation. CONCLUSIONS
The modification of the Devine operation in a smaI1 series of cases has proved to have a Iow enough mortaIity and satisfactory enough end resuIts to warrant its use in postpyIoric uIcers where the uIcers are adherent to the pancreas or in the neighborhood of the papiIIa of Vater. Its use is advocated in patients who have defied medical care and in those where there is no marked gastric retention. I wish to express my thanks to Dr. CharIes W. Lester for having tabuIated the resuIts and to Dr. Lewis Gregory CoIe for much vaIuabIe advice.