Gastric resection for ulcer

GASTRIC RESECTION FOR ULCER* EXPERIENCE

C.

IN FORTY*FOUR

FREMONT VALE,

CASES

M.D.

Associate Surgeon, Harper HospitaI; CIinicaI Professor of Surgery, Wayne University SchooI of Medicine; Attending Surgeon, Receiving Hospital DETROIT,

T

HE trend toward high resection for uIcer is justified by the increasingIy favorabIe Iong range resuIts as compared with those foIIowing Iesser operations, together with a Iowering mortaIity rate as wider experience is obtained. This series of forty-four cases is reported, not because of any exceIIency of resuIts, but to suggest certain factors which we beIieve have enabIed us to operate upon these patients more safeIy. It is recognized today that our medica coIIeagues can treat successfuIIy over 85 per cent of duodenal uIcers. It is with the smaI1 fraction who cannot be reIieved by conservative measures that we are concerned. It is constantIy asked why some cases are so resistant to treatment when the great majority are controIIed. We cannot answer this question compIeteIy. PossibIy a11 wouId be amenabIe to a rigid regime instituted earIy in the disease. However, the IocaI duodena1 pathoIogica1 condition seen at operation is enough to expIain such resistance. In aI of the patients upon whom I have operated for this reason there has been a more or Iess extensive duodenitis with an open uIcer appearing onIy as an area of greatest acuteness. Without exception a11have been adherent to the pancreas. The waII has been thickened and stippIed over a wide area. When the duodenum has been opened, the rugi have appeared Iess free, thickened, often the entire mucosa Iooking much Iike granuIation tissue. These duodena1 waIIs may be compared to the Ieg which has been the site of repeated varicose uIcerations or to one which has heaIed after being severeIy burned. * From the Department

MICHIGAN

SIight trauma which wouId go almost unnoticed on the norma Ieg wiI1 produce a stubborn ulcer. I beheve .we shouId quit thinking and saying “This patient’s ulcer has become active again.” It is in a11 probabiIity not the same uIcer. He has a new uIcer in that chronicaIIy diseased duodenum. Part of this pathoIogica1 condition is due to repeated uIceration and heaIing with deep scar tissue repIacement. MuItipIe uIcers are not uncommonIy observed. In one patient operated upon recentIy the probabIe Iocation of two previous perforations couId be seen and there was an active uIcer on the posterior waI1. In ten cases of resection in which the patients had had free perforations an active uIcer was present posteriorIy. It is suggested that a11 of these individuaIs who cannot be maintained in reasonabIe health and comfort by the internist have such irreversibIe pathoIogica1 changes in the duodena1 waI1, and especiaIIy over the pancreas, that the slightest exciting cause wiI1 produce an uIcer which can be heaIed onIy with great diffrcuIty, if at aI1, and with further damage to the waI1. I do not know why some reach this unfortunate state, but it is easy to see why they can find reIief onIy at the hand of the surgeon. Appreciation of this existing condition is necessary to a wise choice of surgica1 procedure. Since the internist has treated uIcer with such a high measure of success, we surgeons wiI1 do we11 to consider what he does and seek to emmate it. There are four Iocal conditions which he considers and attacks more or Iess directIy by various means.

of Surgery, Wayne University ColIege of Medicine. Read before the CentraI Association, Ann Arbor, February 28, I 94 I.

500

SurgicaI

NEW SERIES VOL. LV, No.

These

conditions

hypermotility,

hyperacidity.

3

VaIe-Resection

are (I) pyIorospasm, (2) (3) hypersecretion, and (4) (Fig. IA.) If these can be

for UIcer

American Journal of Surgery

501

that since these resuIts must Iargely be obtained indirectly they are apt to be more or less incomplete. That this is true is

FIG. I. PS, pylorospasm; HM, hypermotility; HS, h.ypersecretion; HA, hyperacidity. Depth of shading suggests degree of hyperacidity and hypersecrction. A, the stomach with active duodenal ulcer; R, after pyloroplasty; c, n, after resection, which rcafter gastrojejunostomy; moves all factors.

evidenced by the faiIure of pyIoropIasty to continuousIy controIIed, the uIcer usually heals and does not recur as Iong as this cure the patient in too many cases. We control is maintained. have found ulcer recurring Just a little How are these four treatment demands further down beyond the oId suture line. met by our standard operative procedures? In the presence of the duodena1 pathoI. Pytoroplasty is a fairly commonIy logical condition existing in these patients, performed operation. (Fig. IB.) This, it it is an extremeIS optomistic surgeon who would seem, certainly once and for a11 will expect this operation either to be eliminates pyIorospasm by destroying the satisfactoriIy performed or to give permapyIoric sphincter. One who has seen many nent reIief. stomachs, particuIarIy under spinal anesIf there is truth in the Edkin’s hypoththesia, has noted the spasm of the preesis of an acid stimuIating hormone in the pyloric area, and is justified in wondering antral mucosa, pyIoropIasty leaves the just how much is actuaIIy accomplished by patient no better off as far as his acid is concerned. t.he average pyIoropIasty. Finney and HorseIey must have had this in mind when 2. Gastrojejunostoq is supposed to elimthey devised their operations for both inate vicariously the effects of pyIorospasm insisted that the incision be carried well up as a result of the short circuit, and meet the into the prepyIoric portion of the stomach. other indications in much the same way as In addition to the elimination of pyloropyloroplasty, that is, by intragastric respasm, pyloropIasty is supposed to meet gurgitation and freer emptying. (Fig. rc.) the other indications by permitting free This again is an indirect means of attacking back flow of aIkaIine duodenat contents to the probIem. It is notoriously ineffective reduce acidity, and by the unobstructed in the presence of high acidity and the wide opening which removes some of the absence of obstruction. Too often the reason for hypermotiIity as we11 as the patient is given a jejuna1 ulcer and his effects of hypersecretion. It can be seen second state is worse than the first. He will

502

American JournaI of Surgery

VaIe-Resection

devoutIy wish he had his duodena1 uIcer back instead. 3. High resection completely eliminates all of these factors directly and permanently, and is, I believe, the only way in which most patients can be permanentIy cured. /Fig. ID.) In the occasiona case in which JeJunaI uIcer is reported fohowing this operation, there is often doubt as to whether resection has been high enough. One shouId not be satisfied with removal of Iess than three-fourths of the stomach. AI1 of our cases have been fohowed and no jejuna1 uIcer has occurred thus far. Part of our duty is to improve our results individually and colIectiveIy. To this end I am confessing certain errors in technic and judgment. In forty-four resections for ulcer there were six deaths, a mortaIity rate of 13.6 per cent which is entireIy too high. That we have profited by these mistakes is shown by the fact that in our last twentynine resections for a11 conditions there have been onIy two deaths,* one of which occurred in a man eighty years oId with cancer. The first death was due to breaking down of the anastomotic suture line. At that time only two rows of sutures were being used. Since then a third has been added and this disaster has not recurred. The VonPetz clamp has been of major vaIue in faciIitating high resections. The second death was due to poor judgment in attempting to do an excIusion after division just through the pyIoric ring. The duodena1 pathologica condition described above was present and one shouId not expect it to hold. It did not hoId. The next was somewhat simiIar in that not enough duodenal waI1 was separated from the pancreas to make cIosure of the stump secure. We have since Iearned to pIace a finger inside the duodenum as a guide when this dissection is diffrcuIt. Another fata case presents an interesting question. There was a smaI1 fistuIa between the gaIIbIadder and the duodenum. The gaIIbIadder waI1 appeared *On January 7, 1942, forty-two consecutive resections for uker had been completed with one death.

for Ulcer

hl*nctr.

,<,J,

quite norma and the opening in it was inverted and cIosed. It opened, a subdiaphragmatic abscess formed and was drained, but death occurred two months later from a Iiver abscess. If the gaIlbladder had been removed or drained or even had an excIusion been done, this patient wouId almost certainly be aIive. Two of the six deaths were caused by pulmonary comphcations, one on the seventh day due to pneumonia, the other on the thirtieth day due to muItipIe pulmonary abscesses fohowing massive ataIectasis. Both of these cases had intratracheal anesthesia. This method was used in eight of this series with seven major respiratory complications and three deaths. In one, however, the primary cause was abdomina1 and is described above. Intratracheal anesthesia has not been used since and no pulmonary deaths have occurred. I do not wish to decry the method which is invaIuabIe in certain conditions, but in my hands it has been fohowed by a prohibitive rate of respiratory compIications. Twenty patients, or 44.4 per cent of this series, had had together twenty-seven previous operations for ulcer. There were twelve cIosures of acute perforations (two had had two), six gastrojejunostomies (one case had had two), three pyIoropIasties, two degastroenterostomies, one antrumectomy, one excision of uIcer, one partial choIecystectomy and one expIoration with Five of the six deaths appendectomy. occurred in this group. There are seven resections for exclusion with one death referred to above. In the six recoveries the antraI mucosa was not removed, Al1 are cIinicaIIy weI1, one after four years, the others for a shorter time. Three have shown no free acid after alcohol or histamine stimulation. We have not yet succeeded in getting determinations in the others. These resuIts do not tend to support the Edkin’s hypothesis, but the time foIIowing operation is admittedIy too short for fina concIusion. While we think the patient is safer with the pyIorus and the first portion of the duodenum removed, when

the risk seems too great we shall probably continue to do an occasional resection for exclusion, adding, however, excision of the antral mucosa. The operation has been compIeted with antecolic anastomosis without enteroenterostomy seventeen times. The pat’ient who developed liver abscess is the oniy death in this group. In addition, seven have been done foIlowing resection for carcinoma. All results, incIuding h ave had good functiona the one who died two months later. The lirst one was done six years ago. X-ray studies in eight of them have shown no tendency toward stasis in the proxima1 loop. It has been hard for surgeons to get away from the idea that gravity plays an important role in the forward movement of intestinal contents. If the terminal iIeum, cccum and ascending coIon have no dif‘ficuIty in transporting their load from the bottom of the peIvis to the hepatic ffexure, why should we question the ability of the jcjunum to do much less? In twenty-four cases the anterior anastomosis has functioned with complete satisfaction. It is simpler, easier, and therefore more quickly done. The difhculty of attaching the trans\.erse mesocolon to the stump of the stomach after a high resection is eliminated, together with the possibihty of proxima1 loop obstruction. Should subsequent operation be necessary the probIem is much simpIer. This was experienced in one patient who had had an antrumectomy and anterior a nastomosis. We operated three years later for jejunal ulcer with much less difhcuIty than a posterior anastomosis would have caused. We believe at present that there are only three situations in which retrocohc anastomosis may be preferable: First, when resecting for jejunal uIcer folIowing . . j)osterior gastrojejunostomy in which the opening in the transverse mesocolon is aheady present; second, when

there is an unusuahy long transverse mesocolon, and third, when the jejunal mesentery is usually short. In some of the first the anterior method wiII be preferable. Restoration of gastroduodenal continuity by some form of the BilIroth I method has not been used in any cases of ulcer, though we have occasionaIly used it in cancer. The duodena1 pathologica condition increases the immediate operative risk as \velI as that of recurrence. The temptation must also be present to remove Iess of the stomach to facihtate the operation and prevent tension. There still exists much difference of opinion as to the best plan for the surgical treatment of ulcer and also in detail of technic. I cIose by making a plea that results be reported frankIy, the bad, which we hesitate to publish, as well as the good. Only in this way can we reach the goal of reasonabIy safe, permanently curative surgery in the ulcer patient. SUMMARY I. Extensive duodenitis is suggested as the reason some patients cannot be controlled on a medical regime. 2. The abihty of standard operations to relieve pyIorospasm, hypermotility, hypersecretion and hyperacrdity, which is the aim of medicaI treatment, is discussed. Resection alone completely fulfils these requirements. 3. Errors in technic and judgment are described, correction of which has reduced the mortality rate. 4. Resection for exclusion has given good results and is recommended for those patients in whom complete resection carries too great a risk. The prepyloric mucosa shouId be removed. 5. AntecoIic anastomosis without jejunojejunostomy- is the method of choice in the majority of cases.