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Gastric resection for carcinoma of the stomach
GASTRIC
RESECTION FOR CARCINOMA STOMACH* J. SHELTON
HORSLEY,
RICHMOND,
T
HE first pyIorectomy for cancer was done by P&an in 1879. Rydigier, of Austria, aIso performed the operation in I 880, but when in February, 1881, BiIh-oth, of Vienna, reported the first successfuI case of partiaI gastrectomy, a new era of gastric surgery was created. PartiaI gastrectomy is divided into two genera1 cIasses:-the BiIIroth I operation, in which the stump of the stomach is united to the duodenum, and the BiIIroth II, in which the stump of the stomach is united to the jejunum or in which the stump of the stomach is cIosed and a gastroenterostomy is done. Subsequent operations are usuaIIy referred to as modifications of the BiIIroth I or the BiIIroth II methods, such as the FinneyHaberer modification of the BiIIroth I, or the PoIya or Hofmeister modification of the BiIIroth II. This cIassification has the advantage of indicating at once the type of procedure. The BiIIroth I type of operation was abandoned by BiIIroth because of the “deadIy triangIe,” so-caIIed because, when the Iine of sutures cIosing the stump of the stomach met the sutures which united the duodenum to the stomach, Ieakage was IikeIy to occur in the Y-shaped suture Iine. ApparentIy in the original technic the duodenum was sutured to the stomach aIong the Iesser curvature, but in order to prevent a diverticuIum or cul-de-sac of the fundus of the stomach, WijIfler suggested that BilIroth wouId in the future insert the duodenum into the greater curvature. The Billroth rr method seems to have been first suggested in 1885, by Von * Read at a Round Table Conference
OF THE
M.D.
VA.
Hacker, an assistant of BiIIroth, soon after he described posterior gastroenterostomy. At that time there was no definite knowIedge of the motor physioIogy of the stomach and of the importance of the Iesser curvature, which has been demonstrated Iater by AIvarez, Klein, and others. It is now known that the Iesser curvature is the site of the initia1 gastric peristaIsis and that the cardiac end of the stomach contracts tonicaIIy as a rubber bag or hopper forcing the food into the right haIf of the stomach which has active peristalsis. The peristaIsis that roentgenoIogicaIIy seems to begin about the middIe of the body of the stomach, has been shown by AIvarez to start as rippIes high up on the Iesser curvature and after increasing in force to proceed, as Gregory CoIe and others have demonstrated, in cycIes toward the pyIoric end. The tissues aIong the Iesser curvature, though they may not histoIogicaIIy resemble such structure, physiologicaIIy act as neuromuscuIar tissue, somewhat as the sino-auricular node of the heart, and a Iesion here usuaIIy quickIy manifests itseIf by a disturbance of peristaIsis and symptoms of indigestion. The greater curvature and the cardiac portion of the stomach, with much of the adjacent gastric walls, are physioIogicaIly “siIent” as far as indicating the presence of a Iesion is concerned, unIess there is bIeeding, perforation or obstruction. These facts are important not. onIy in the diagnosis of gastric disease, but in preserving physioIogic function during resection if this can be done without sacrificing the chances of cure.
on Cancer at the Fiftieth 1934. 240
Anniversary
of the Memorial
HospitaI, May 24,
NEW
SERIES VOL. XxX1,
No. z
Horsley-Gastric
Local v-shaped resections of cancer of the stomach are practicaIIy never justifiable. Gastroenterostomy has little, if any for cancer of the place, in operations stomach. If the neopIasm can be removed by part.iaI gastrectomy, and the obstructing mass of tissue extirpated, it seems to be a better procedure than gastroenterostomy, even if there is a small metastasis outside of the stomach or in the Iiver which cannot be excised. With Iocal anesthesia and efficient preliminary and after treatment, the increased danger of partiaI gastrectomy over gastroenterostomy. is but shght, and the greater advantages m the comfort and proIongation of Life are consi.derabIe. Whatever type of operation is to be done for cancer of the stomach, certain prehminary preparations are essential. Correcting anemia by transfusion, or dehydration by the admmistration of water and the eIectroIvtes by proctocIysis, hypodermoclysis or y intravenous injection, is important. If the cancer is uIcerating or fungoid, contains many pyogenic and saprophytic bacteria, and there is none of the natural antiseptic effect of hydrochloric acid, the danger of postoperative peritonitis is greatIy increased. This danger can be mitigated by the administration of diIute hydrochIoric acid for at Ieast forty-eight hours before the operation. The patient is given a pitcher of a 0.23 to 0.3 per cent hydrochIoric acid soIution, which is sweetened, and is requested to drink it as often as possibIe. The stomach is occasionaIIy lavaged with the same solution. The choice of anesthetics is important. In patients who are past sixty years of age, a IocaI anesthetic is preferabIe. NaturaIly the anesthetic must be fitted to the particuIar case, but a genera1 anesthesia in eIderIy cancer patients is aIways accompanied by considera bIe risk. The BiIIroth I type of operation is usuahy preferred to the BiIIroth II. However, in many conditions this technic is not possibIe, as when the duodenum itseIf is diseased or there is considerable contracture of the tissues and the stump of the
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stomach cannot be brought to the duodenum. But by proper mobihzation, lifting up the stump of the stomach, cIamping and severing the gastric artery and stretching and dividing any retaining bands or adhesions aIong the stump of the stomach, the stomach may be often mobilized to a surprising extent and can be brought over to the duodenum more readiIy than would at first appear. The stomach can then empty into the duodenum, which is its physioIogic receptacle. No attempt is made to cataIogue the various technics of partiaI gastrectomy for they can be readiIy found in works on surgery, but I shaI1 describe the methods that I have found most satisfactorv. As I have aIready mentioned, if the conditions permit, some type of Billroth I operation appears to be preferabIe to the BiIlroth II. Keeping in mind the radical removal of the cancer as the first indication and the restoration of function as a cIose second, the physioIogicaIIy active portion of the stomach, which is aIong the Iesser curvature, shouId be ahned in its norma position to the upper border of the duodenum. SafeIy suturing the thick stomach wall to the comparatively thin duodenal wall may be diffrcuh, unIess a large amount of tissue is invaginated, when obstruction may resuh. This objection of obstruction can be met by incising the anterior waI1 of the duodenum for a distance of I to ~)i inches, thus flaring open the duodenum and making a kind of funnel out of it, so that obstruction would be practicaIIy impossible. The objection to the “deadIy triangle” which was the cause of fatalities in the BiIJroth I operation can also be obviated. When the duodenum is united along the greater curvature of the stomach, Ieakage may occur where the sutures closing the upper portion of the stump of the stomach meet the suture line that unites the stomach to the duodenum. The upper portion of the stump of the stomach is comparativeIy more fixed than the lower portion, and cannot be so readiIy infolded. The Iower portion is mobiIe and the redundant part
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of the stump at the greater curvature can be easily inverted by a purse-string suture which is reinforced by suturing the adjoining fat over it. Another point in favor of the BiIIroth I method is that the site of operation is confined to the immediate IocaIity of the disease. There is no occasion for Iifting up the transverse coIon, making a rent in the mesocoIon, or other procedures that may conceivabIy tend to promote metastasis or infection by smearing bacteria or cancer ceIIs over points at some distance from the site of the excision. Then, too, this type Iends itseIf somewhat more readiIy to IocaI anesthesia. The technic of the modification of the BiIIroth I operation which I deveIoped and have used for ten years is as fohows: After gentIe expIoration and determination of the extent of the disease the gastrohepatic omentum is opened. The vesseIs aIong the Iesser curvature at the proposed Iine of resection are doubIy cIamped and divided, preferabIy with the cautery. The stomach is Iifted and with the hand in the Iesser peritonea1 cavity the gastrocoIic omentum is identified and opened. The vesseIs aIong the gastrocolic omentum near the transverse coIon are doubIy cIamped and divided. When the pyIoric end of the stomach is reached, care must be taken to avoid injury to the mesocohc vesseIs which are quite cIose to the pyIorus. The pyIoric vessels are doubIy cIamped and divided about opposite the pylorus. IncidentaIIy, I have seen a congenita1 fusion of the transverse mesocoIon with the Iower portion of the waI1 of the stomach, which caused an injury to the mesocoIic vesseIs. This, of course, is unusua1, but shouId be borne in mind, and it is for this reason that it is preferabIe to enter the Iesser peritonea1 cavity from above. The vesseIs are controIIed by transfixing and tying the tissues around them with pIain catgut. AIong the curvatures two Iigatures are tied and the ends of the d&a1 Iigature are Ieft Iong. Two stout Payr cIamps are pIaced across the body of the stomach and ordinary pedicIe
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or KeIIy clamps across the duodenum. The duodenum is divided between the two cIamps with the cautery, as is the stomach between the two Payr cIamps. The stump of the stomach is further mobiIized, if necessary, by Iifting it up and dividing the gastric artery or any retaining bands. The stump of the duodenum may be freed from the pancreas for a short distance by dissection preferabIy with the cautery. The stump of the stomach is brought over to the stump of the duodenum and is fastened by interrupted mattress sutures of hne tanned or chromic catgut in such a manner that the Iesser curvature of the stomach is in Iine with the upper border of the duodenum. It is best to pIace a11 of these sutures before any are tied and after tying them, to Ieave the upper and Iower ends Iong as tractor sutures. The site of the operation is packed around with moist gauze, and the Payr cIamp is removed from the stump of the stomach, and any bleeding points are cIamped. The pedicIe cIamp on the duodenum is next removed and its contents withdrawn by suction. In cases of obstruction it wiI1 sometimes be found that, even though the stomach has been washed out several times, food is retained. I have seen cases in which corn or beans, eaten days before the operation, stiI1 remained in the stomach. If there is reason to suspect this, a smaI1 IadIe is sterirized with the instruments to dip out any retained materia1 which cannot be drawn through the suction apparatus. Then the remaining portion of the stomach is gentIy creansed with saIt soIution, which is then aspirated. Beginning on the mucosa of the upper portion of the stump of the stomach at the Iesser curvature, a suture of No. I tanned or chromic catgut in a curved needIe is inserted, going through the Iesser curvature from within outward, and through the upper border of the duodenum from without inward, then tied, and the short end cIamped. The suture is continued downward as a Iockstitch, uniting the posterior margin of the stump of the stomach to the
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posterior margin of the stump of the duodenum unti1 the Iower border of the duodenum is reached. Then, with the finger within the duodenum as a guide, an incision about I to IM inches (2.5 to 3 cm.) Iong is made in the anterior surface of the duodenum a IittIe beIow its center. This hares the duodenum and permits the continuation of this Iockstitch for about two stitches farther. Sometimes, if the stomach is not large, an actua1 end-to-end union may be made. There is usuaIIy a redundancy of the stump of the stomach, which is cIosed by continuing this suture to the Iower border of the stomach where it is tied and the ends are cIamped. A second suture of the same materia1 begins at the Iesser curvature as the preceding suture, going from within outward on the stomach and from without inward on the upper border of the duodenum. The short end of this is tied to the end of the preceding suture and these two ends are cut rather Iong. This suture is continued down anteriorIy, uniting the anterior waI1 of the stump of the stomach to the anterior waI1 of the stump of the duodenum. An extra hitch of the stitch may be taken over any bIood vesseI. The suture is appIied as far as possible from within, drawing it snugIy as it emerges from the mucosa on the Ieft-hand side. This tends to invert the border of the stomach and at the same time affords hemostasis which a continuous mattress or right angIe suture does not aIways effect. This suture is terminated at the Iower border of the stump of the stomach. A purse-string suture of No. oo tanned or chromic catgut in a round needIe is inserted at the Iower border of the stump of the stomach, turning in the redundant teat. The suture is carried upward as a right angIe continuous suture with an occasiona backstitch, inverting the preceding Iine of sutures, and is terminated at the Iesser curvature. Additiona interrupted mattress sutures of No. oo tanned or chromic catgut are pIaced at the Iesser curvature. The Iong ends of the Iigatures on the
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vesseIs of the lesser curvature and the upper border of the duodenum are tied together. An additiona suture of catgut is aIs0 inserted over this. It must be remembered that in this region is the active peristaIsis and, consequentIy, considerabIe strain upon the sutures. At the lower border of the stomach an additional purse-string suture of No. oo tanned or chromic catgut is placed, and some adjacent peritonea1 covered fat is brought over and caught in this suture for further security. The ends of the Iigatures aIong the gastrocoIic omentum are IooseIy tied together. One or two interrupted mattress sutures of fine catgut may be pIaced aIong the anterior Iine of sutures for reinforcement. This operation is very satisfactory in most cases. OccasionaIIy, however, there are conditions which wiI1 not permit of its performance. When a BiIIroth II type seems to be indicated, the Hofmeister operation is usuaIIy advisabIe. Here the upper portion of the stump of the stomach is cIosed and the Iower portion is united to the jejunum, much as in a posterior gastroenterostomy. Care must be taken, however, not to make too much of a snout aIong the Iower border. In order to avoid that, it is we11 to Ieave an abundant stoma at the Iower border, and probabIy it wouId be better to cut back the tissues aIong the greater curvature--so that the infoIding of the upper stump wiI1 not prevent emptying, as has happened in one of my own cases. If the stomach is extensiveIy invoIved with cancer, or if the cardiac portion is affected, a tota gastrectomy may be indicated. This operation shouId have a wider fieId than it occupies at present. WhiIe it is necessariIy dangerous, if the proper preparations are made and the technic carefulIy carried out the risk shouId not be prohibitive. NaturaIIy, certain types of Iinitis pIastica in which the size of the stomach has been greatIy reduced offer a heId for this operation and
244
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in such cases the technic shouId be comparativeIy easy. If tota gastrectomy is indicated, in an earIy stage of the operation the insertion of a cannuIa,* or, better stiI1, pIacing a Iarge soft rubber catheter in some unaffected portion of the stomach and fixing it with a purse-string suture, is heIpfu1. The catheter is connected at intervaIs with the suction apparatus and so keeps the stomach empty. The duodenum is severed, and the attachments of the stomach are clamped and divided unti1 the stomach is Ieft attached soleIy at the esophagus. Care must be taken to secure the coronary vein, which runs aIong the Iesser curvature, and to which attention is not aIways caIIed. After the vesseIs have been Iigated, the stomach is raised. The suggestion of Moynihan to use the stomach as a kind of handle to the esophagus is usefu1 at this stage. A Ioop of jejunum, is seIected rather far down in order to give ampIe pIay with no traction on its mesentery. CIamps or rubber bands are so pIaced as to isoIate the portion of the jejunum that is to be united to the esophagus. The esophagus is somewhat mobilized, and its posterior border is exposed by Iifting the stomach onto the thorax, making suction at intervaIs through the rubber catheter to prevent regurgitation of the gastric contents into the esophagus. The posterior waI1 of the esophagus is united to the jejunum with a continuous suture of siIk or Iinen and the suture Iocked and temporariIy abandoned. An incision of about 1% inches (3.74 cm.) is made into the jejunum, making it about equa1 to the diameter of the esophagus. The esophagus is aIso incised and suction appIied to both of these wounds. Beginning on the right side, the posterior margin of the wound in the jejunum is sutured to the posterior margin of the wound in the esophagus with a continuous suture of Iinen or siIk in a smaI1 curved needIe. When the Ieft side is reached, the suture is continued forward, severing the esophagus as it proceeds. The suture is tied to its *Recommended by H. B. Devine, of AustraIia.
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origina end. The first row of sutures is again taken up and buries the inner row. SeveraI interrupted sutures are pIaced for additiona security, and if possibIe some adjacent peritonea1 covered fat may be brought over the Iine of union. It is doubtIess best to put a Iong drainage tube through a stab wound, leading from the region which the cardiac end of the stomach occupied to a stab wound in the Ieft flank. An accumuIation of serum and fluid in this region may occur which, if not drained away, may produce a subdiaphragmatic abscess, as happened in one of my cases. Instead of cIosing the stump of the duodenum, I beIieve a better procedure (which I have tried once) wouId be to suture the duodenum into an incision in the right Ioop of jejunum. An enteroenterostomy is made between the two Ioops of the jejunum where they cross the transverse coIon. BeIow the enteroenterostomy, a tube enterostomy, according to the method of Witzel or Coffey, is made for feeding purposes, and the tube is brought out through a stab wound on the Ieft side. NaturaIly there must be variations in these technics to satisfy the IocaI conditions. For instance, if the Iesion aIong the Iesser curvature is extensive or adherent the gastrocoIic omentum shouId be opened first, and the stomach severed from the duodenum and its cardiac portion, separating the attachments of the Iesser curvature Iast. If the stomach is adherent to the pancreas, the adherent area shouId be dissected up with the eIectric cautery, going into the pancreas and. avoiding penetration into the stomach. If the coIon is invoIved, either directIy or by its mesenteric vesseIs, and requires excision, the resection of the stomach is compIeted, then the vesseIs in the mesocoIon are divided. FinaIIy the affected portion of the coIon is excised by doubIy cIamping the two ends of the Ioop to be removed and dividing the coIon between the cIamps with the cautery. The ends of the coIon are thoroughIy cauterized and
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Ieft intact until after al1 the suturing on the stomach is completed. They may then be united, preferabIy by an end-to-end suture, and a right coIostomy made Iower down through a muscIe spIitting incision; or, if this seems unwise, the coIostomy malbe estabIished and the abdomina1 wound closed, bringing the stumps of the colon into the wound and Ieaving the cramps on as- in the so called obstructive resection. Later, the union of the two stumps can be secured either by the second stage of a MikuIicz operation, or some other procedure. WhiIe we must have so-caIIed standard procedures for the average case of gastric cancer, these methods shouId be modified, entirely changed, or abandoned, according to thevindications as they arise. OccasionaIIy Iesions that appear aImost hopeIess and inoperabIe may be satisfactoriI7 removed. This shouId not mean reckIess surgery, but it does impIy a carefu1 consideration of the conditions as they exist, not only the type
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of maIignancy, its Iocation and extent, but aIso the patient’s resistance, while bearing in mind, too, that there is no hope whatever for these patients without excision of the cancerous growth, REFERENCES ALVAREZ, WALTER C. The Mechanics of the Digestive Tract, ed. 2, New York, 1928, PauI B. Hoeber, Inc. COLE, L. G. The complex motor phenomena of various types of unobstructed gastric peristalsis, Arch. Roentg. Ray, 191 I, 16: 242-247. Motor phenomena of the stomach, pyIorus and cap observed roentgenographically, Am. J. Physiol., 1917, 42: 618-619. DEVINE, H. B. Basic principIes and supreme dificuIties in gastric surgery. Surg., Gynec. @ Obst., 1925, 40: 1-16. HORSLEY, J. SHELTON. Surgery of the Stomach and Duodenum, 1933, St. Louis, The C. V. 31osby Co. PP. 195-235. KLEIN, EUGENE. Gastric motility, I. The origin and character of gastric peristalsis. Arch. Surg., 1926, 12: 571-582. Gastric motility, II. The conduction of the gastric peristaItic wave. Arch. Surg., 1926, 12: 583-590. MOYUIHAN, SLR BERKELEY. Abdominal Operations, Co., Philadelphia and Vol. 1, W. B. Saunders I .ondon, I 926.
RESECTION FOR CARCINOMA STOMACH* J. SHELTON
HORSLEY,
RICHMOND,
T
HE first pyIorectomy for cancer was done by P&an in 1879. Rydigier, of Austria, aIso performed the operation in I 880, but when in February, 1881, BiIh-oth, of Vienna, reported the first successfuI case of partiaI gastrectomy, a new era of gastric surgery was created. PartiaI gastrectomy is divided into two genera1 cIasses:-the BiIIroth I operation, in which the stump of the stomach is united to the duodenum, and the BiIIroth II, in which the stump of the stomach is united to the jejunum or in which the stump of the stomach is cIosed and a gastroenterostomy is done. Subsequent operations are usuaIIy referred to as modifications of the BiIIroth I or the BiIIroth II methods, such as the FinneyHaberer modification of the BiIIroth I, or the PoIya or Hofmeister modification of the BiIIroth II. This cIassification has the advantage of indicating at once the type of procedure. The BiIIroth I type of operation was abandoned by BiIIroth because of the “deadIy triangIe,” so-caIIed because, when the Iine of sutures cIosing the stump of the stomach met the sutures which united the duodenum to the stomach, Ieakage was IikeIy to occur in the Y-shaped suture Iine. ApparentIy in the original technic the duodenum was sutured to the stomach aIong the Iesser curvature, but in order to prevent a diverticuIum or cul-de-sac of the fundus of the stomach, WijIfler suggested that BilIroth wouId in the future insert the duodenum into the greater curvature. The Billroth rr method seems to have been first suggested in 1885, by Von * Read at a Round Table Conference
OF THE
M.D.
VA.
Hacker, an assistant of BiIIroth, soon after he described posterior gastroenterostomy. At that time there was no definite knowIedge of the motor physioIogy of the stomach and of the importance of the Iesser curvature, which has been demonstrated Iater by AIvarez, Klein, and others. It is now known that the Iesser curvature is the site of the initia1 gastric peristaIsis and that the cardiac end of the stomach contracts tonicaIIy as a rubber bag or hopper forcing the food into the right haIf of the stomach which has active peristalsis. The peristaIsis that roentgenoIogicaIIy seems to begin about the middIe of the body of the stomach, has been shown by AIvarez to start as rippIes high up on the Iesser curvature and after increasing in force to proceed, as Gregory CoIe and others have demonstrated, in cycIes toward the pyIoric end. The tissues aIong the Iesser curvature, though they may not histoIogicaIIy resemble such structure, physiologicaIIy act as neuromuscuIar tissue, somewhat as the sino-auricular node of the heart, and a Iesion here usuaIIy quickIy manifests itseIf by a disturbance of peristaIsis and symptoms of indigestion. The greater curvature and the cardiac portion of the stomach, with much of the adjacent gastric walls, are physioIogicaIly “siIent” as far as indicating the presence of a Iesion is concerned, unIess there is bIeeding, perforation or obstruction. These facts are important not. onIy in the diagnosis of gastric disease, but in preserving physioIogic function during resection if this can be done without sacrificing the chances of cure.
on Cancer at the Fiftieth 1934. 240
Anniversary
of the Memorial
HospitaI, May 24,
NEW
SERIES VOL. XxX1,
No. z
Horsley-Gastric
Local v-shaped resections of cancer of the stomach are practicaIIy never justifiable. Gastroenterostomy has little, if any for cancer of the place, in operations stomach. If the neopIasm can be removed by part.iaI gastrectomy, and the obstructing mass of tissue extirpated, it seems to be a better procedure than gastroenterostomy, even if there is a small metastasis outside of the stomach or in the Iiver which cannot be excised. With Iocal anesthesia and efficient preliminary and after treatment, the increased danger of partiaI gastrectomy over gastroenterostomy. is but shght, and the greater advantages m the comfort and proIongation of Life are consi.derabIe. Whatever type of operation is to be done for cancer of the stomach, certain prehminary preparations are essential. Correcting anemia by transfusion, or dehydration by the admmistration of water and the eIectroIvtes by proctocIysis, hypodermoclysis or y intravenous injection, is important. If the cancer is uIcerating or fungoid, contains many pyogenic and saprophytic bacteria, and there is none of the natural antiseptic effect of hydrochloric acid, the danger of postoperative peritonitis is greatIy increased. This danger can be mitigated by the administration of diIute hydrochIoric acid for at Ieast forty-eight hours before the operation. The patient is given a pitcher of a 0.23 to 0.3 per cent hydrochIoric acid soIution, which is sweetened, and is requested to drink it as often as possibIe. The stomach is occasionaIIy lavaged with the same solution. The choice of anesthetics is important. In patients who are past sixty years of age, a IocaI anesthetic is preferabIe. NaturaIly the anesthetic must be fitted to the particuIar case, but a genera1 anesthesia in eIderIy cancer patients is aIways accompanied by considera bIe risk. The BiIIroth I type of operation is usuahy preferred to the BiIIroth II. However, in many conditions this technic is not possibIe, as when the duodenum itseIf is diseased or there is considerable contracture of the tissues and the stump of the
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American Journal of Surgery
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stomach cannot be brought to the duodenum. But by proper mobihzation, lifting up the stump of the stomach, cIamping and severing the gastric artery and stretching and dividing any retaining bands or adhesions aIong the stump of the stomach, the stomach may be often mobilized to a surprising extent and can be brought over to the duodenum more readiIy than would at first appear. The stomach can then empty into the duodenum, which is its physioIogic receptacle. No attempt is made to cataIogue the various technics of partiaI gastrectomy for they can be readiIy found in works on surgery, but I shaI1 describe the methods that I have found most satisfactorv. As I have aIready mentioned, if the conditions permit, some type of Billroth I operation appears to be preferabIe to the BiIlroth II. Keeping in mind the radical removal of the cancer as the first indication and the restoration of function as a cIose second, the physioIogicaIIy active portion of the stomach, which is aIong the Iesser curvature, shouId be ahned in its norma position to the upper border of the duodenum. SafeIy suturing the thick stomach wall to the comparatively thin duodenal wall may be diffrcuh, unIess a large amount of tissue is invaginated, when obstruction may resuh. This objection of obstruction can be met by incising the anterior waI1 of the duodenum for a distance of I to ~)i inches, thus flaring open the duodenum and making a kind of funnel out of it, so that obstruction would be practicaIIy impossible. The objection to the “deadIy triangle” which was the cause of fatalities in the BiIJroth I operation can also be obviated. When the duodenum is united along the greater curvature of the stomach, Ieakage may occur where the sutures closing the upper portion of the stump of the stomach meet the suture line that unites the stomach to the duodenum. The upper portion of the stump of the stomach is comparativeIy more fixed than the lower portion, and cannot be so readiIy infolded. The Iower portion is mobiIe and the redundant part
242
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of the stump at the greater curvature can be easily inverted by a purse-string suture which is reinforced by suturing the adjoining fat over it. Another point in favor of the BiIIroth I method is that the site of operation is confined to the immediate IocaIity of the disease. There is no occasion for Iifting up the transverse coIon, making a rent in the mesocoIon, or other procedures that may conceivabIy tend to promote metastasis or infection by smearing bacteria or cancer ceIIs over points at some distance from the site of the excision. Then, too, this type Iends itseIf somewhat more readiIy to IocaI anesthesia. The technic of the modification of the BiIIroth I operation which I deveIoped and have used for ten years is as fohows: After gentIe expIoration and determination of the extent of the disease the gastrohepatic omentum is opened. The vesseIs aIong the Iesser curvature at the proposed Iine of resection are doubIy cIamped and divided, preferabIy with the cautery. The stomach is Iifted and with the hand in the Iesser peritonea1 cavity the gastrocoIic omentum is identified and opened. The vesseIs aIong the gastrocolic omentum near the transverse coIon are doubIy cIamped and divided. When the pyIoric end of the stomach is reached, care must be taken to avoid injury to the mesocohc vesseIs which are quite cIose to the pyIorus. The pyIoric vessels are doubIy cIamped and divided about opposite the pylorus. IncidentaIIy, I have seen a congenita1 fusion of the transverse mesocoIon with the Iower portion of the waI1 of the stomach, which caused an injury to the mesocoIic vesseIs. This, of course, is unusua1, but shouId be borne in mind, and it is for this reason that it is preferabIe to enter the Iesser peritonea1 cavity from above. The vesseIs are controIIed by transfixing and tying the tissues around them with pIain catgut. AIong the curvatures two Iigatures are tied and the ends of the d&a1 Iigature are Ieft Iong. Two stout Payr cIamps are pIaced across the body of the stomach and ordinary pedicIe
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or KeIIy clamps across the duodenum. The duodenum is divided between the two cIamps with the cautery, as is the stomach between the two Payr cIamps. The stump of the stomach is further mobiIized, if necessary, by Iifting it up and dividing the gastric artery or any retaining bands. The stump of the duodenum may be freed from the pancreas for a short distance by dissection preferabIy with the cautery. The stump of the stomach is brought over to the stump of the duodenum and is fastened by interrupted mattress sutures of hne tanned or chromic catgut in such a manner that the Iesser curvature of the stomach is in Iine with the upper border of the duodenum. It is best to pIace a11 of these sutures before any are tied and after tying them, to Ieave the upper and Iower ends Iong as tractor sutures. The site of the operation is packed around with moist gauze, and the Payr cIamp is removed from the stump of the stomach, and any bleeding points are cIamped. The pedicIe cIamp on the duodenum is next removed and its contents withdrawn by suction. In cases of obstruction it wiI1 sometimes be found that, even though the stomach has been washed out several times, food is retained. I have seen cases in which corn or beans, eaten days before the operation, stiI1 remained in the stomach. If there is reason to suspect this, a smaI1 IadIe is sterirized with the instruments to dip out any retained materia1 which cannot be drawn through the suction apparatus. Then the remaining portion of the stomach is gentIy creansed with saIt soIution, which is then aspirated. Beginning on the mucosa of the upper portion of the stump of the stomach at the Iesser curvature, a suture of No. I tanned or chromic catgut in a curved needIe is inserted, going through the Iesser curvature from within outward, and through the upper border of the duodenum from without inward, then tied, and the short end cIamped. The suture is continued downward as a Iockstitch, uniting the posterior margin of the stump of the stomach to the
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posterior margin of the stump of the duodenum unti1 the Iower border of the duodenum is reached. Then, with the finger within the duodenum as a guide, an incision about I to IM inches (2.5 to 3 cm.) Iong is made in the anterior surface of the duodenum a IittIe beIow its center. This hares the duodenum and permits the continuation of this Iockstitch for about two stitches farther. Sometimes, if the stomach is not large, an actua1 end-to-end union may be made. There is usuaIIy a redundancy of the stump of the stomach, which is cIosed by continuing this suture to the Iower border of the stomach where it is tied and the ends are cIamped. A second suture of the same materia1 begins at the Iesser curvature as the preceding suture, going from within outward on the stomach and from without inward on the upper border of the duodenum. The short end of this is tied to the end of the preceding suture and these two ends are cut rather Iong. This suture is continued down anteriorIy, uniting the anterior waI1 of the stump of the stomach to the anterior waI1 of the stump of the duodenum. An extra hitch of the stitch may be taken over any bIood vesseI. The suture is appIied as far as possible from within, drawing it snugIy as it emerges from the mucosa on the Ieft-hand side. This tends to invert the border of the stomach and at the same time affords hemostasis which a continuous mattress or right angIe suture does not aIways effect. This suture is terminated at the Iower border of the stump of the stomach. A purse-string suture of No. oo tanned or chromic catgut in a round needIe is inserted at the Iower border of the stump of the stomach, turning in the redundant teat. The suture is carried upward as a right angIe continuous suture with an occasiona backstitch, inverting the preceding Iine of sutures, and is terminated at the Iesser curvature. Additiona interrupted mattress sutures of No. oo tanned or chromic catgut are pIaced at the Iesser curvature. The Iong ends of the Iigatures on the
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vesseIs of the lesser curvature and the upper border of the duodenum are tied together. An additiona suture of catgut is aIs0 inserted over this. It must be remembered that in this region is the active peristaIsis and, consequentIy, considerabIe strain upon the sutures. At the lower border of the stomach an additional purse-string suture of No. oo tanned or chromic catgut is placed, and some adjacent peritonea1 covered fat is brought over and caught in this suture for further security. The ends of the Iigatures aIong the gastrocoIic omentum are IooseIy tied together. One or two interrupted mattress sutures of fine catgut may be pIaced aIong the anterior Iine of sutures for reinforcement. This operation is very satisfactory in most cases. OccasionaIIy, however, there are conditions which wiI1 not permit of its performance. When a BiIIroth II type seems to be indicated, the Hofmeister operation is usuaIIy advisabIe. Here the upper portion of the stump of the stomach is cIosed and the Iower portion is united to the jejunum, much as in a posterior gastroenterostomy. Care must be taken, however, not to make too much of a snout aIong the Iower border. In order to avoid that, it is we11 to Ieave an abundant stoma at the Iower border, and probabIy it wouId be better to cut back the tissues aIong the greater curvature--so that the infoIding of the upper stump wiI1 not prevent emptying, as has happened in one of my own cases. If the stomach is extensiveIy invoIved with cancer, or if the cardiac portion is affected, a tota gastrectomy may be indicated. This operation shouId have a wider fieId than it occupies at present. WhiIe it is necessariIy dangerous, if the proper preparations are made and the technic carefulIy carried out the risk shouId not be prohibitive. NaturaIIy, certain types of Iinitis pIastica in which the size of the stomach has been greatIy reduced offer a heId for this operation and
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in such cases the technic shouId be comparativeIy easy. If tota gastrectomy is indicated, in an earIy stage of the operation the insertion of a cannuIa,* or, better stiI1, pIacing a Iarge soft rubber catheter in some unaffected portion of the stomach and fixing it with a purse-string suture, is heIpfu1. The catheter is connected at intervaIs with the suction apparatus and so keeps the stomach empty. The duodenum is severed, and the attachments of the stomach are clamped and divided unti1 the stomach is Ieft attached soleIy at the esophagus. Care must be taken to secure the coronary vein, which runs aIong the Iesser curvature, and to which attention is not aIways caIIed. After the vesseIs have been Iigated, the stomach is raised. The suggestion of Moynihan to use the stomach as a kind of handle to the esophagus is usefu1 at this stage. A Ioop of jejunum, is seIected rather far down in order to give ampIe pIay with no traction on its mesentery. CIamps or rubber bands are so pIaced as to isoIate the portion of the jejunum that is to be united to the esophagus. The esophagus is somewhat mobilized, and its posterior border is exposed by Iifting the stomach onto the thorax, making suction at intervaIs through the rubber catheter to prevent regurgitation of the gastric contents into the esophagus. The posterior waI1 of the esophagus is united to the jejunum with a continuous suture of siIk or Iinen and the suture Iocked and temporariIy abandoned. An incision of about 1% inches (3.74 cm.) is made into the jejunum, making it about equa1 to the diameter of the esophagus. The esophagus is aIso incised and suction appIied to both of these wounds. Beginning on the right side, the posterior margin of the wound in the jejunum is sutured to the posterior margin of the wound in the esophagus with a continuous suture of Iinen or siIk in a smaI1 curved needIe. When the Ieft side is reached, the suture is continued forward, severing the esophagus as it proceeds. The suture is tied to its *Recommended by H. B. Devine, of AustraIia.
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origina end. The first row of sutures is again taken up and buries the inner row. SeveraI interrupted sutures are pIaced for additiona security, and if possibIe some adjacent peritonea1 covered fat may be brought over the Iine of union. It is doubtIess best to put a Iong drainage tube through a stab wound, leading from the region which the cardiac end of the stomach occupied to a stab wound in the Ieft flank. An accumuIation of serum and fluid in this region may occur which, if not drained away, may produce a subdiaphragmatic abscess, as happened in one of my cases. Instead of cIosing the stump of the duodenum, I beIieve a better procedure (which I have tried once) wouId be to suture the duodenum into an incision in the right Ioop of jejunum. An enteroenterostomy is made between the two Ioops of the jejunum where they cross the transverse coIon. BeIow the enteroenterostomy, a tube enterostomy, according to the method of Witzel or Coffey, is made for feeding purposes, and the tube is brought out through a stab wound on the Ieft side. NaturaIly there must be variations in these technics to satisfy the IocaI conditions. For instance, if the Iesion aIong the Iesser curvature is extensive or adherent the gastrocoIic omentum shouId be opened first, and the stomach severed from the duodenum and its cardiac portion, separating the attachments of the Iesser curvature Iast. If the stomach is adherent to the pancreas, the adherent area shouId be dissected up with the eIectric cautery, going into the pancreas and. avoiding penetration into the stomach. If the coIon is invoIved, either directIy or by its mesenteric vesseIs, and requires excision, the resection of the stomach is compIeted, then the vesseIs in the mesocoIon are divided. FinaIIy the affected portion of the coIon is excised by doubIy cIamping the two ends of the Ioop to be removed and dividing the coIon between the cIamps with the cautery. The ends of the coIon are thoroughIy cauterized and
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Ieft intact until after al1 the suturing on the stomach is completed. They may then be united, preferabIy by an end-to-end suture, and a right coIostomy made Iower down through a muscIe spIitting incision; or, if this seems unwise, the coIostomy malbe estabIished and the abdomina1 wound closed, bringing the stumps of the colon into the wound and Ieaving the cramps on as- in the so called obstructive resection. Later, the union of the two stumps can be secured either by the second stage of a MikuIicz operation, or some other procedure. WhiIe we must have so-caIIed standard procedures for the average case of gastric cancer, these methods shouId be modified, entirely changed, or abandoned, according to thevindications as they arise. OccasionaIIy Iesions that appear aImost hopeIess and inoperabIe may be satisfactoriI7 removed. This shouId not mean reckIess surgery, but it does impIy a carefu1 consideration of the conditions as they exist, not only the type
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of maIignancy, its Iocation and extent, but aIso the patient’s resistance, while bearing in mind, too, that there is no hope whatever for these patients without excision of the cancerous growth, REFERENCES ALVAREZ, WALTER C. The Mechanics of the Digestive Tract, ed. 2, New York, 1928, PauI B. Hoeber, Inc. COLE, L. G. The complex motor phenomena of various types of unobstructed gastric peristalsis, Arch. Roentg. Ray, 191 I, 16: 242-247. Motor phenomena of the stomach, pyIorus and cap observed roentgenographically, Am. J. Physiol., 1917, 42: 618-619. DEVINE, H. B. Basic principIes and supreme dificuIties in gastric surgery. Surg., Gynec. @ Obst., 1925, 40: 1-16. HORSLEY, J. SHELTON. Surgery of the Stomach and Duodenum, 1933, St. Louis, The C. V. 31osby Co. PP. 195-235. KLEIN, EUGENE. Gastric motility, I. The origin and character of gastric peristalsis. Arch. Surg., 1926, 12: 571-582. Gastric motility, II. The conduction of the gastric peristaItic wave. Arch. Surg., 1926, 12: 583-590. MOYUIHAN, SLR BERKELEY. Abdominal Operations, Co., Philadelphia and Vol. 1, W. B. Saunders I .ondon, I 926.