Does anterior gastrojejunostomy predispose to development of jejunal ulceration?

DOES ANTERIOR GASTROJEJUNOSTOMY PREDISPOSE TO DEVELOPMENT OF JEJUNAL ULCERATION?* A STUDY BASED UPON NINETY CHARLES S. KENNEDY, M.D.

PARTIAL

AND

ROLAND

Chief of SurgicaI Staff, Grace HospitaI DETROIT,

Attending

P. REYNOLDS,

M.D.

Surgeon, Grace IIospitaI

MICHIGAN

ITH the graduaI shift of surgical opinion in the past twenty years away from short circuiting operation for “peptic ulcers” to sub-tota gastrectomy, different types of operation were proposed. There has been a graduaI evohrtion of surgical technic beginning with the BiIIroth I to the present day PoIy6, PoIyb-BaIfour, Moynihan, MikuIicz, Hoffmeister-Finsterer operations. In generaI, it has been found to make IittIe difference just which type of resection and anastomosis is made provided the method is sufficientIy radica1 to permit of wide resection. There appears to be some controversy of opinion as to whether an anterior gastrojejunostomy or a posterior gastrojejunostomy shouId be done. Each type of operation has its proponents. It has been said that the anterior gastrojejunostomy, aIthough much simpIer to perform, is not as satisfactory as the posterior gastrojejunostomy since the jejuna1 mucosa much further removed from the stomach is exposed to an unaccustomed gastric content and hence the danger of jejunal uIceration deveIopment is greater. l This group would have us beIieve that because the posterior gastrojejunostomy utiIized a Ioop of jejunum much cIoser to the stomach, its mucosa was much better able to receive the insuIt of direct reception of gastric contents. We have undertaken this study based upon ninety partial gastrectomies for “ peptic uIcer ” in an effort to determine whether the anterior gastrojejunostomy

does predispose to the deveIopment of a jejuna1 uIcer. If it can be shown that the mucosa of the jejunum 30 cm. from the Iigament of Treitz is as resistant to the irritating effect of the gastric contents as that much cIoser to the ligament, then that particuIar objection to the anterior gastrojejunostomy wouId cease to exist. The ease with which an anterior gastrojejunostomy can be done as compared to the posterior gastrojejunostomy and its absolute freedom from the danger of injury to the middIe coIic artery, which may occur during the posterior gastrojejunostomy, wouId indeed make it the procedure of choice in a11 partia1 gastrectomies. In our series of ninety cases, we used the anterior PoIy6 type of anastomosis. Seven of the cases required a Hoffmeister modification of the PoIyb technic. This modification was found very usefu1 in those cases in which the Iesion was unusuaIIy high up on the Iesser curvature and a safer anastomosis couId be made by cIosing a part of the stomach stoma. A Iong Ioop of anterior to the jejunum was brought transverse coIon and the point of anastomosis was made 30 to 40 cm. from the Iigament of Treitz. In a11 of our cases, we removed sufficient stomach to create a postoperative achIorhydria or hypochlorhydria. In order to standardize our operative technic as far as is possibIe we used as the upper Iine of our gastric incision, the point at which the Ieft gastric artery reaches the Iesser curvature, and the Iower Iine of the incision reaches the bare (avascuIar) area of the stomach which is

W

* From the Department

GASTRECTOMIES

of Surgery, Grace Hospital. 36

VI,,

I ‘XXII,

VII

I

Kennedy,

ReynoIds---GastrojejunostomJ-

AmericanJournal

nf~uryC

years old , and Both pa1 ;ients the opera .tions

see] 1 between the Ieft and the right gastro(Fig. I) Bv removing a11 epil )Ioic arteries. distal to the I&e of incision the stomach

est patient was tn-enty-two the oldest \vas sel’enty-two. had excellent results from

just described, a11 the stomach that is necessarv to be removed for a good result was exc~ised. In this way, all the acidforming tissue was removed from the stomach and aIso the antral mucosa which appears to reguIste acid secretion.2 Since all the acicl-forming tissue has been removed at operation, we have been abIe to produce an achIorhydria with the resuIt that the irritating effect of the hydrochloric acid from the gastric secretion cannot be considered a factor in the production of jejuna1 uIcers postoperati\,cIy. \Vich the remova of this chemical factor ;LS a possible etiological agent in the production of jejunal uIcers, \ve are left onI,v with the mechanics1 irritative factor resulting from the discharge of gastric contents onto a jejunal mucosa Lvhich is not accustomed to it. A g1anc.e at the tabuIated histories reveals so~ne interesting data. Our young-

performed. Eight\--two of the patients bvere males and only eight were females. Sixtynine of the patrents were operated upon for duodens ulcer and twenty-one patients number of had gastric ulcers. The largest patients Lvere between fifty to sist! years old. The age of the patient in no wa\ influenced the decision to do a par&I It is the physical condition gastrectoniy. of the patient that determined the operabiIity. L2’e did not perform an enteroenterostomv in a single case in association with our anterior gastrojejunostomies. Many of these patients were operated upon live Jears ago so that adequate time to has elasped for jejuna1 uIceration de\-eIop if this operation predisposed to it. In our follow-up of these ninety patients, we found not a single patient had developed a jejunal ulceration. When we compare this Lvith studies taken from lrarious surgical centers throughout the countr!

38

American

Journal

of surgery

Kennedy,

TABLE PATIENTS

I

OPERATED

-

UPON*

Name Name

H. C. 2. L. B. M. 3. J. K. I.

4. J. K.

5. S. I. G. 6. G. N. 7. G. H. 8. W. W. B. y. H. L. IO. J. C. II. c. H. 12. A. L. T. 13. W. F. G. 14. c. ,M. 15. T. S. 16. E. E. 17. H. A. 18.

J. B.

19. R. T.

20. M. B. 21. c. M. 22. H. G. 23. T. J. 24. L. V. 25. G. A. 26. R. S. L. 27. W. hf. 28.

s.

J. M.

29. A. W. 30. D. H. 31.

J. I-I. M.

32. 33. 34. 35. 36. 37. 38. 39. 40.

H. L. A. B. J. B. E. 0. E. H. A. P. C. T. W. F. B. C. B.

41.

50.

G. A. M. K. H. E. D. S. E. h4. L. B. J. M. A. M. F. K. W. B.

51.

I. w.

52. 53. 54. 55. 56. 57. 58. 59.

J. .I. K. K. C. W. G.

42. 43. 44. 45. 46. 47. 48. 49.

M.

F. F.

W.

I(. II.

H. M. F. G. W. P. M. G. hf.

Sex

M F h4 h4 h4 M M M IhI M h4 F h4 hl F M M M M M M M 1M M M h4 M M M M M M M ; M hl nr hl F AI F M M

hI M M $1 M M h4 M

hf M M i12 F M M

Age 22 27

27 27 30 32 32 32 31 34 38 39 40 41 41 4* 41 42 43 43 43 44 44 45 45 44 46 47 47 47 47 47 48 48 49 47 48 48 50 50 50 50 51 51 5’ 5’ 51 52 52 52 53 53 54 54 54 55 55 55 57

JULY, 1946

Reynolds-Gastrojejunostomy TABLE

-

I (Continued)

-

Age

Sex

Diagnosis

Diagnosis

DuodenaI ulcer Gastric ulcer Duodenal uIcer Gastric ulcer Duodenal ulcer Duodenal uker Duodenal ulcer DuodenaI ulcer Duodenal uIcer Gastric uIcer DuodenaI ulcer DuodenaI ulcer Duodenal ulcer Duodenal uIcer Gastric uker DuodenaI ulcer Duodenal ulcer Gastric uker Duodenal ulcer Duodenal ulcer Duodenal uIcer Gastric ulcer DuodenaI ulcer DuodenaI uker DuodenaI ulcer Duodenal uker Duodenal ulcer Duodenal ulcer Gastric ulcer Duodenal ulcer Duodenal uker DuodenaI ulcer Duodenal ulcer Duodenal ulcer Duodenal ulcer Duodenal ulcer Gastric ulcer Duodenal ulcer Duodenal ulcer Gastric uker Duodenal uIcer hlarginal ulcer DuodenaI ulcer Duodenal uker DuodenaI ulcer Duodenal ulcer Gastric ulcer Duodenal ulcer Duodenal ulcer Duodenal ulcer Duodenal ulcer Duodenal ulcer Duodenal ulcer Duodenal ulcer Duodenal ulcer Gastric uker Duodenal ulcer Duodenal ulcer DuodenaI ulcer

_. ._. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71.

H. B. E. E. M. S. .I. H. R. R. A. W. T. P. J. H. C. A. B. C. E. J. L. M. C. 72. J. W. 73. L. P. 74. I-I. w. 75. IV. H.

76. 77. 78. 79. 80. 81. 82.

h4. D. T. H. I-1. J. D. G. A. H. H. F. J. C. C. J. K.

83. G. M. 84. J. G.

85. 86. 87. 88. 89. 90.

D. E. G. H. A. R.

W. 0. G. B. P. W. K. C.

h4

56 56 56 58 58 59 59 59 57 57 57 34

Al M F M M M ICI &I M M kI M F M M hsl M M IV1 M ht M hl F

5’ 36 5’ 60 60 61 61 62 62 62 64 66 66

M RI M M

71 77 72 47 56 53

M M

Gastric ulcer DuodenaI uIcer Gastric ulcer Gastric ulcer Gastric uIcer DuodenaI uIcer Gastric ulcer Duodenal uIcer DuodenaI uker Gastric uker Duodenal utter DuodenaI uIcer DuodenaI ulcer Duodenal uker Duodenal ulcer Duodenal uIcer DuodenaI ulcer Gastric ulcer Duodenal ulcer Gastric uker DuodenaI ulcer Gastric ulcer DuodenaI ulcer DuodenaI uker DuodenaI uker DuodenaI ulcer Gastric uIcer DuodenaI uIcet Duodenal ulcer Duodenal ulcer Duodenal ulcer

*The trectomy

operation in each case was sub-total and a11 the patients recovered.

gas-

performing posterior gastrojejunostomy, it becomes evident that the resuIts we obtained at Grace HospitaI are quite favorable. In performing our sub-tota gastrectomies, we aIways make it a point to fasten the proxima1 loop of jejunum to the Iesser curvature just above the anastomosis for a distance of 3 cm. This suture prevents regurgitation of the stomach contents into this proximal loop of jejunum. COMMENT

Any method of gastrojejunostomy which can be performed with a minimum of hazard should be the operation of choice. Since sufficient gastric acid-forming tissue and the sntra1 mucosa is removed at operation to render the gastric contents reIativeIy achIorhydric postoperativeIy, it

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makes littie difference from a chemica1 irritant point of \-iew as to whether the mucosa of a short loop or a long Ioop of jejunum is exposed to the gastric contents. 11:~ have been able to demonstrate in our series of ninetv cases that the mucosa of :L long loop of jejunum can withstand the mechanica irritating efl‘ects of the gastric contents as we11 as the rnucosa of the short loop of jejunum. The choice of operation I\-ould depend then upon which could be (lone with greater safety. The posterior gastrojejunostomy becomes \‘er> dil‘ficult in a patient, having a short mesocolon or a ‘Ler> fattjr mesocoIon so that the middle colic artery- cannot be readily identified. An injury to the middle colic artery in the performance of a posterior gas~:rojejunostom~ does occur e\-en in the best surgical centers.” This necessitates resection of the colon and thus adds to the operat i\ c morbidity and risk. If the anastomosis is performed to the right of the middlra colic artery instead of to the let’t, the rc.sults are not too good. By the use of the anterior gastrojejunostom~ all these pit-f:\lIs are avoided; and since \ve h:r ye demo tnstrated that the anterior gas-

trojejunostomy does not predispose to the devek~pment of jejuna1 ulcers, \ve believe it to be the operation of choice. In no case did we perform an enteroenterostomy with the gastrojejunoqtonn?.

I. Anterior gastrojejunostomy does not predispose to the deveIopment of iejunal ulcers. 2. The mucosa of the jejunum in the long loop is :rbIe to withstand the effects of receiving the gastric contents directI> as well as the n~ucosn of the jejunurn closer to the stornacbh. 3. Bv using the anterior gastrojejunostomy, \;-ithout entero-enterostomy, a11 danger of injury to the middle coIic artery is

avoided. REFERENCES I.

PROII

am,

J. \-. Pq)tic

ulcer. S. Clin. !Vortl~ .~meri~(l.

24: jo -59, 1044.

Basis

of Medical Practice. 3rd. d. ihltink~, and Wilkins Co. S. J. SurgicaI management 01 chronic ulcer. S. Clin. North Am&u, 24.: 018-6~.

1943. Wrlliarns

3.

.\IARSHALL,

peptic

IO44