Elective surgery for duodenal ulcer—A graded approach

Elective

Surgery for Duodenal Graded Approach

are we11 aware that there is no singIe perfect operation for chronic duodena uIcer, for if there were one, its superiority wouId be accIaimed without hesitation. As it is today, operations for chronic duodena1 uIcer may be cIassed in one of three groups: (I) subtota gastric resection; (2) vagotomy with a drainage procedure, such as gastroenterostomy or pyIoropIasty; (3) vagotomy with a smaI1 gastric resection (removal of 50 per cent or less of the stomach). Any of these operations may be foIIowed by the catastrophe of death. That the death rate may be generaIIy higher than we wouId Iike to beIieve it to be, is suggested by the results of a recent survey* conducted by the Ohio Chapter of the American CoIIege of Surgeons and pubIished in this JournaI. In the composite figures taken from a number of leading hospitaIs the mortaIity is 4.3 per cent for a tota of 2,562 eIective operations performed by 432 surgeons. It is significant that the mortaIity is 4.9 per cent for those operations associated with gastric resection (about 80 per cent of a11 the operations), whereas it is onIy 1.7 per cent for a11 Iesser procedures. I beIieve both rates to be too high for elective operations. As surgeons, we shouId be dissatisfied with a mortality rate far exceeding that generaIIy reported for hysterectomy Since eIective gastric or choIecystectomy. resection for duodena1 uIcer usuaIIy is reported as accompanied by a mortaIity rate greater than 2 per cent, even by surgeons with a Iarge experience, perhaps the intrinsic risk of the operation is too great to justify its routine appIication to a benign condition. There must be vaIid reasons why a cIearIy safer procedure such as vagotomy and gastro-

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URGEONS

* Survey Committee (S. 0. Hoerr, Chairman), Ohio Chapter, American CoIIegeof Surgeons.EIective operations performed for duodenal uker, with their mortality; results of a survey in selected Ohio hospitals. Am. .I. Surg., 96: 365-368, 1958.

Ulcer-A

enterostomy is not more wideIy used. The reason is to be found in the higher recurrence rate of a duodena1 or stoma1 uIcer after these Iesser procedures. This recurrence rate has been reported to be as high as 8 per cent, in comparison with uIcer recurrence rates of Iess than I per cent after vagotomy with Iimited gastric resection. Has not too much attention been paid to recurrent uIceration as a cause of faiIure, and too IittIe attention to fataIity rate and, in particuIar, to the Ioss of weight and maInutrition which may foIIow gastric resection? In about haIf the patients who experience a recurrent uIcer after vagotomy with a bypass or a drainage operation the ulcer is we11 controIIed with simpIe medications and dietary precautions-not to be confused with an ultrastrict medica regimen-and the patients regard themseIves as adequateIy benefited by their operations. The remainder can, if necessary, undergo a secondary gastric resection, which wiI1 give them a11 the benefits, insofar as avoidance of recurrent uIcer is concerned, they wouId have experienced if gastric resection had been performed in the first place. In my experience, approximately 5 per cent of patients who have had vagotomy with gastroenterostomy wiI1 require a secondary gastric resection within five to ten years. It is a noteworthy cIinica1 observation that these secondary operations are just as safe as primary resections and indeed may actuaIIy be safer, since the duodena1 uIcer usuaIIy is quiescent and the inffammation in this area, which increases the risk, has disappeared. There is an additiona technica reason why surgeons have not adopted in greater measure vagotomy with a drainage procedure. As a coroIIary of overemphasis on recurrent uIceration as a cause of faiIure, and of underemphasis on death rates and nutritiona crippIing, many abIe surgeons have not bothered to master the technica detaiIs of the performance of a good

Editorial surgeon shouId perfect his technic of subdiaphragmatic vagotomy, and Iearn the wide, one-layer, Heineke-MikuIicz pyIoropIasty advocated by Weinberg or the carefu1 dependent placement of a gastroenterostomy-detaiIs that are functionahy essentia1 to proper gastric emptying and an effective operation. Perhaps he shouId constantIy recaI1 the maxim, “you can always take some stomach out, but you cannot put it back in,” and should view with equanimity the secondary gastric resection that occasionally is needed.

subdiaphragmatic vagotomy. In comparison with the proficiency they show with gastric resection, they perform their occasiona vagotomy with difficulty, and sometimes inadequately. Every surgeon who has had a Iarge experience with vagotomy and a drainage procedure has called attention to the necessity of the search for and division of smaI1 vagus fibers that are so frequentIy present and that may prevent a good result if left undivided. Perhaps knowIedge yet to be acquired wiI1 guide us to the selection of the best operation for the particuIar patient with better effect than is now possibIe. UntiI that time, perhaps the surgeon shouId view with greater satisfaction the 80 to 85 per cent of benetited patients aftervagotomy and gastroenterostomy, and note the relative absence of fatalities and postoperative nutritiona woes. Perhaps the

STANLEY 0. HOERR, M.D., Department of General Surgery, Tbe Cleveland Clinic Foundation: and The Frank E. Bunts Educational Institute, Cleveland, Ohio

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