Gastrectomy for carcinoma

GASTRECTOMY

FOR CARCINOMA*

CASE REPORT OF OLDEST PATIENT TO SURVIVE M.

G. GILLESPIE,

M.D.

Chief of Surgery, St. Luke’s Hospital DULUTH,

T

MINNESOTA

OTAL gastrectomy is becoming a more frequent operation. According to Finney and Rienhoff, Phineus

FIG. I. Preoperative ffuoroscopy reveating tensiveness of carcinoma.

ex-

Conner of Cincinnati performed the first tota gastrectomy in 1884. The patient did not recover. However, in 1897, SchIatter performed the first successfu1 tota gastrectomy. In 1929, Finney and Rienhoff coIIected from the Iiterature sixty-seven cases of tota gastrectomy, and Raeder reported * From the Department

eighty-eight cases up to 1933. Since that time the operation of totaI gastrectomy has become a more frequent occurrence. The Mayo CIinic reported twenty-seven tota gastrectomies between 1907 and 1938, and sixteen since 1937. Arthur W. AIIen, reporting the experience at the Massachusetts Genera1 HospitaI, Iisted fifteen cases between the years 1932 and 1938. Lahey, in 1939, reported nine cases. Besides these, a number of singIe case. reports have been pubIished and it is known that other smaI1 groups of cases have not as yet been reported irl the literature. According to Waiters, the indications for tota gastrectomy for carcinoma are three: (I) The Iesion should be confined entireIy to the stomach without evidence of metastases. (2) The entire stomach and Iower end of the esophagus shouId be suffIcientIy mobile to enabIe the surgeon to remove the stomach and to make the esophagojejuna1 anastomosis without too much diffIcuIty. (3) The genera1 condition of the patient should be good, so that the risk assumed is not too great. The mortality rate, as might be expected, is high. Finney and Rienhoff reported in the coIIected group of sixty-seven cases a mortaIity rate of 53.8 per cent. AIIen, in the group of fifteen cases from the Massachusetts Genera1 HospitaI, reported 7 deaths. Lahey stated that in the nine cases of total gastrectomy, there were five surgicaIIy

of Surgery, The DuIuth Clinic, Duluth, Minnesota. Staff Meeting, Duluth, October 16, 1941.

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successfu1. According to DonaId, in the Mayo CIinic series of twenty-seven cases between rgo7 and 1938, there were onIy

FIG. 2.

nine survivaIs,

Gross

specimen operation.

removed

or a mortality

at

in

and Giffin

REPORT

W. S., age seventy-nine, consulted Dr. P. G. Boman, August 25, 1941, because of epigastric

W. S., age seventy-nine, seven weeks postoperativety.

rate of 6635

causes

CASE

349

FIG. 3. Mr.

per cent. However, in the sixteen tota gastrectomies since 1937, the mortahty rate decreased to 31 per cent. The cause of death, according to Finney and Rienhoff, as one might expect, was peritonitis in 58 per cent, shock in 22 per cent, and misceIIaneous cent. According to Waugh

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Proceedings of tbe Mayo Clinic for June 4, years oId, upon I 94 I, a patient seventy-two whom they had performed a total gastrectomy, represented the oIdest person to undergo tota gastrectomy successfuIIy as far as they couId ascertain from the Iiterature. I wish to present the foIIowing case of a man, age seventy-nine, as the oldest individuaI to undergo a successfuI gastrectomy for carcinoma.

pain and distress. This distress dated back three months. The pain was constant and dull in character. He had a poor appetite and had lost fifteen pounds in weight. There was also an associated weakness, and constipation. The patient had first been seen in the CIinic in 1917, at the age of fifty-five. He then gave a history that for twenty-five years he had had stomach trouble. He was examined by Dr. T. R. Martin and found to have an achIorhydria. Stomach fluoroscopy was negative. He was treated with diIute hydrochIoric acid. In 1923, a bilateral herniotomy was performed by Dr. Braden. FolIowing this he had a cystitis and prostatitis, and was under the care of Dr. NichoIson. In x927, he consulted Dr. P. G. Boman, because of stomach distress, and again it was found that he had an absence of free hydrochloric acid. A stomach fIuoroscopy was negative. He was treated with dilute hydrochIoric acid.

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GiIIespie-Gastrectomy

In 1937, he was treated for frequency of urination by Dr. NichoIson. In 1938, he consulted Dr. Boman and it was

FIG. 4 X-ray view of the esophagojejuna1 anastomosis twenty-seven days postoperatively.

that he stiII had an absence of free hydrochloric acid. The stomach IIuoroscopy, as before, was found to be negative. Treatment with hydrochloric acid was resumed. In 1941, he was treated for a prostatitis by Dr. NichoIson. Family and marital histories were irrelevant. Examination showed this elderly man to be rather thin, weighing 12034 pounds. He showed evidences of weight 10s~. Despite this, he was quite we11 preserved for his years. There was some evidence of chronic emphysema. His bIood pressure was I 10/80. The heart and Iungs were normal for his age. AbdominaI examination reveaIed a mass on ffuoroscopy associated with the stomach (Fig. I), which Dr. Boman beIieved to be an inoperable carcinoma of the stomach. Test meal reveaIed an absence of free hydrochIoric acid and there was three pIus occult blood present. Examination of the bIood showed the hemogIobin to be 12.5 Cm. or 85 per cent, the red blood count 4,510,ooo. The urine was negative for albumin and sugar. The patient was toId that he had an extensive carcinoma of the stomach which probabIy couId

found

l

not be removed. However, he .and his famiIy elected to have an expIoration, and therefore he entered the hospital, September I, 1941. September 3 he was expIored. Anesthesia was accompIished with ethylene and ether vapor. It was found that there was a diffuse carcinomatous invoIvement of the stomach extending from the pyIorus aImost to the esophagus. However, the stomach was not attached and there were no evidences of peritonea or Iiver metastases. There were, however, a few enIarged gIands in the gastrocoIic and gastrohepatic Iigaments. It was decided to attempt a tota gastrectomy. The gastrocoIic omentum was first divided along the greater curvature. The duodenohepatic Iigament was then divided, and the duodenum cut across just dista1 to the pylorus. The duodenum was inverted. The attachments to the spIeen were divided, which aIIowed for greater mobility. The right gastric artery was then divided and Iigated. In this way, we were abIe to mobilize the cardia and the esophagus. A Ioop of the jejunum was brought up through the mesocolon, and an anastomosis was made with a layer of interrupted siIk No. I sutures and two rows of No. o chromic catgut. The suture Iine was reinforced with omentum. A jejunojejunostomy was then performed. A gastro-enterostomy tube which had previously been inserted was then brought down through the anastomosis we11 aIong into the dista1 loop of the jejunum. FinaIIy, the mesocolon was sutured about the Ioop of the jejunum. A penrose drain was inserted beIow the inferior surface of the Iiver. Two Gm. of sulfanilamide powder were Ieft in the operative area and another 2 Gm. were pIaced in the wound during its cIosure. He was given 500 cc. of 5 per cent glucose and I ,000 cc. of titrated bIood during the course of the operation. The operative procedure took aImost three hours. At the cIose, his systoIic bIood pressure was 120 and the diastoIic pressure 70. Dr. A. H. WeIIs* submitted the foIlowing report on the gross specimen (Fig. 2): “Specimen consists of a Iarge mass of stomach, incIuding about 2 cm. of the duodenum. When spread out it measures 20 cm. Iong and 12 cm. wide. The entire pyIoric end, incIuding * Pathologist, Minnesota.

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the pyloric vaIve, over an area measures about 13 cm. in Iength is hard, diffuseIy and severeIy thickened, but apparentIy not extending into the duodenum. The mucosal surface over this area is fixed and gray. The submucosa and muscularis are uniformIy indurated, gray, firm and thickened, averaging 146 cm. in breadth. The serosa is Iikewise unusuaIIy gray and fixed to deeper tissues. At the fundal end there is apparentIy 4 cm. of norma appearing mucosa. There is no uIceration of the involved mucosa1 surface. “Microscopic: There is a wiId, very diffuse invasion throughout the various Iayers of the gastric waI1 by highIy anapIastic and very smaI1 epitheIia1 ceIIs. OccasionaIIy these ceIIs form definite gIanduIar structures. “Diagnosis: Scirrhous carcinoma of stomach (Ng-dz-ca. stomach).” Feedings through the gastro-enterostomy tube were begun on the second day. For two or three days there was rather profuse drainage through and about the penrose drain, but this graduaIIy decreased, and his wound healed without infection. The gastro-enterostomp tube was removed on the fifth postoperative day, and thereafter frequent smaI1, ora feedings were given. He was aIIowed out of bed on the

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ninth postoperative day and Ieft the hospita1 on the sixteenth postoperative day. SUMMARY

A patient (age seventy-nine) is presented who was operated upon for carcinoma of the stomach. TotaI gastrectomy was performed. The patient made an uneventfu1 convaIescence and I beIieve is the oIdest patient to survive this procedure. At the time of this writing, aImost three months folIowing operation, his recovery has continued to run a smooth course. REFERENCES I. ALLEN, ARTHUR W. Carcinoma of stomach: with special reference to tota gastrectomy. Ann. Surg., 107: 770, 1938. 2. DONALD, C. J., JR. TotaI gastrectomy: report of a case. Proc. Staff Meet., Mayo Clin., 16: 446, 1941. 3. FINNEY, JOHN M. T. and RIENHOFF, WM. FRANCIS, JR. Gastrectomy. Arch Surg., 18: 140, 1929. 4. LAHEY, FRANK H. Experiences with gastrectomy, total and subtotat. New England J. Med., 220: 315, 1939. 5. WAUGH, J. M. and GIFFIN, L. A. TotaI gastrectomy

and part&I esophagectomy for carcinoma: report of successfu1 operation for oIdest known patient. Proc. Staff. Meet., Mayo Cl&., 16: 363, 1941.