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Indications for and end results of surgery in the treatment of duodenal ulcer
INDICATIONS FOR AND END RESULTS OF SURGERY IN THE TREATMENT OF DUODENAL ULCER GEORGE CRILE,
M.D.,
AND
GEORGE
CRILE,
JR., M.D.
CIeveIand Clinic CLEVELAND,
I
N rg22,35 per cent of the patients with duodena1 uIcer seen at the CIeveIand CIinic were subjected to surgica1 operations. In 1937 onIy 5 per cent of the patients with duodena1 uIcer required surgica1 treatment. In the past fifteen years, therefore, we have become seven times more conservative in recommending operative treatment for duodena1 uIcer. This trend toward the conservative management of duodena1 uIcer is the resuIt not onIy of the superior methods of medical management that the gastroenteroIogist now has at his disposal, but aIso of the experience gained in foIIowing more than 2600 patients with duodena1 uIcer, many of whom, especiaIIy in the earIier days, were subjected to surgica1 operations. An anaIysis of the results in IOO consecutive cases of duodena1 uIcer treated by surgery indicates that our growing conservatism and desire to manage these patients on a medica regimen is we11 justified. Yet we should Iike to emphasize again that certain of the compIications of duodena1 ulcer such as perforation, persistent or recurrent obstruction, and recurrent hemorrhage, demand surgica1 intervention and that the best interest of the patient wiI1 be served if surgery in these cases is not deIayed. ANALYSIS OF 100 CONSECUTIVE CASES OF DUODENAL ULCER TRFATED BY SURGERY The indications for operation in IOO consecutive cases of duodena1 uIcer treated by surgery are given in TabIe I. The operations performed for the reIief of these symptoms are shown in Table II. Seventy-four per cent of these patients were foIIowed for from six months to ten
OHIO TABLE LEADING
SYMPTOMS
I BEFORE
OPERATION
Per Cent 54
Pain.............................. Obstruction. Bleeding........................,, Acute perforation..
26 12
8
years after operation, an average foIIow-up period of forty-six and one-half months. TABLE OPERATIONS
II PERFORMED
Per Cent Posterior gastroenterostomy. . 72 Resection of stomach (posterior polya in the majority of cases). 14 Closure of perforated ulcer. 6 PyIoropIasty. . . 5 Posterior gastroenterostomy and plication of perforated ulcer.. . 2 Anterior gastroenterostomy. I RESULTS
FOLLOWING
POSTERIOR
GASTROENTEROSTOMY
As indicated in TabIe I, posterior gastroenterostomy was the operation of choice in seventy-two of the IOO cases. In this series, there were three hospita1 deaths, a mortality rate of 4.2 per cent. In sixteen cases, the gastroenterostomy was performed for obstruction. Fourteen, or 87.5 per cent, of these patients obtained compIete reIief of a11 symptoms referable to TABLE RESULTS
OF
POSTERIOR FOR
III GASTROENTEROSTOMY
OBSTRUCTION
Sixteen Cases (Post-Operative
Deaths Not IncIuded)
Result
Completely relieved. PartiaIIy relieved. No relief.. . TotaI........................
.
14
.
87.50 6.25 6.25
I I .I
16
)
Ioo
I24
American Journal of Surgery
CriIe and Crile,
Jr.-DuodenaI
uIcer or obstruction. One patient (6.2 per cent) obtained partiaI reIief, and one patient obtained no relief. (TabIe III.) The end resuIts of gastroenterostomy in thirty-three patients whose outstanding compIaint was pain were Iess satisfactory than when the Ieading symptom was obstruction. In 60.6 per cent of the cases, complete reIief of symptoms was obtained, but it shouId be noted that a few of the patients found it necessary to remain on a guarded diet in order to avoid a recurrence of symptoms. PartiaI reIief was obtained in 18.2 per cent, and 2 1.2 per cent failed to obtain any striking reIief of symptoms unIess they adhered to a rigid medical regimen. (TabIe IV.) TABLE Iv RESULTS OF POSTERIOR GASTROENTEROSTOMY FOR PAIN Thirty-three
Cases
(Post-Operative
Result
Completely relieved. ............ PartiaIly relieved. ............... No relief .......................
TotaI ........................
Deaths
ExcIuded)
Number of Cases
Per Cent of Total Cases
-I
20 6 7
-I
33
60.6 18.2 21.2 100
The results of gastroenterostomy for pain must therefore be cIassified as being good onIy in conjunction with dietary management of the uIcer. Operation aIone cannot be considered to effect compIete and permanent relief of pain in a11 cases. The results in the oIder patients were distinctIy better than in the younger, permanent reIief of symptoms being 20 per cent more common in patients over 45 years of age than in those under 45. In five cases, posterior gastroenterostomy was performed because of a history of recurrent hemorrhage from a duodena1 uIcer. Four of these five patients had no recurrence of the hemorrhage and in one case there was a recurrence of the bIeeding. (TabIe v.)
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APRIL, 1938
TABLE v RESULTS OF POSTERIOR GASTROENTEROSTOMY FOR BLEEDING Five Cases (Post-Operative Deaths
Not IncIuded)
I
I Number of Cases
I
Completely No relief..
relieved.
~~$~n~ Cases
I4 I (recurrence of hemorrhage)
80 20
The end resuIts of gastroenterostomy for obstruction, pain, and bIeeding are summarized in TabIes III, IV, and v. It is cIear from the foregoing data that the best resuIts folIowing posterior gastroenterostomy are obtained when obstruction is present. When gastroenterostomy is to be performed for pain or hemorrhage, it must be with the understanding that the patient wiI1 continue to foIIow a guarded diet and wiI1 consider the gastroenterostomy as an adjunct to medica management. It has been our experience, however, that ulcers which are intractabIe to medica therapy before operation wiI1 usuaIIy yieId readiIy to treatment after gastroenterostomy is performed. GASTRIC
RESECTION
The post-operative mortaIity rate from gastric resection has been approximateIy three times as great as that from gastroenterostomy. Gastric resection is therefore an operation which, in the absence of specia1 indications, shouId not be advised for a disease which is essentiaIIy benign. In addition, aIthough gastric resection effects a cure of the uIcer in the great majority of cases, it has been our experience that in some cases this procedure repIaces the symptoms of uIcer with other types of distress which may be equaIIy annoying to the patient. Thus, 20 per cent of the patients having gastric resections compIained of gastric symptoms comparabIe in severity to those produced by the uIcer which had been resected and in
NEW SERIES VOL. XL, No.
I
CriIe and CriIe,
Jr.-DuodenaI
one instance hemorrhage from a gastrojejunaI ulcer occurred. It is doubtIess a satisfaction to the surgeon to have cured the duodena1 uIcer, but the patient cannot enjoy this satisfaction if he continues to experience pain. Many of the patients whose stomachs had been resected were forced to foIIow a guarded diet in order to be free of symptoms and hence the postoperative course of the patients with gastric ahhough the uIcer may be resections, cured, may entail as much attention to diet and as much gastric distress as is reported to occur in patients subjected to more conservative procedures. The greater mortaIity rate associated with gastric resection shouId influence the decision, wherever possibIe, in favor of the more conservative measures. DISCUSSION
From the foregoing data, it is clear that gastric surgery, and particuIarIy the more radicaI and hence more dangerous types of gastric surgery, ahhough perhaps curing the uIcer, do not aIways resuIt in the compIete and permanent reIief of gastric distress. In addition, as Gray1 has stated, “Promiscuous resection of the stomach for duodena1 ulcer does not seem to be warranted. The risk of a fata outcome with this procedure is probabIy greater than is the possibihty of obtaining an unsatisfactory functiona result or a recurrent or anastomotic ulceration with the more conservative surgicaI measures.” For these we have become progressively reasons, more conservative in recommending radical surgery for patients with duodena1 uIcer. Although we now beIieve that, with careful medical management, over g5 per cent of the patients with duodena1 ulcer can carry on their norma activities in safety and comfort, there are certain complications of peptic uIcer which demand surgicaI intervention. The first of these is acute perforation. The perforation shouId be cIosed as soon as possibIe and no further surgery should be attempted at this time. In our experi-
UIcer
A merican Journal of Surgery
125
ence, the mortaIity rate foIIowing gastroenterostomy and cIosure of a perforated uIcer has been UnjustifiabIy high. We beIieve with Roscoe Graham2 that in the presence of a perforated uIcer the surgeon shouId “dea1 in the most simpIe manner onIy with the Iesion which creates the hazard to Iife.” Graham records thirty-six consecutive operations for perforated uIcer without a death. Pyloric obstruction may occur as the resuIt of inflammatory edema, spasm, or actuaI cicatricia1 stenosis secondary to a duodenal uIcer, and often wiII be compIeteIy reheved by skiIfu1 medica management with the patient at rest in the hospitaI for a few days to two weeks. If, however, no reIief is obtained or if the obstruction recurs, posterior gastroenterostomy wilI give prompt and permanent reIief with maximum safety. Obstructing duodena1 uIcers rareIy recur after gastroenterostomy. Hence, in cases with obstruction, resection of the ulcer or resection of the stomach are unnecessary and, in view of the increased mortaIity rate associated with these procedures, they are undesirable. The mortaIity rate in patients with bIeeding duodena1 uIcer treated conservativeIy is considerabIy higher than has been generaIIy recognized. The recent studies of Kiefer3 show that the mortaIity rate in this condition is approximateIy 5 per cent. As AIIen and Benedict4 have shown, this mortality rate increases with advancing age and with each succeeding hemorrhage. Thus in patients beyond middIe age who have previousIy had one or more hemorrhages, the case fataIity is higher than the post-operative mortaIity rate of a conservative operation for duodena1 uIcer. In the Lahey series,5 it has been observed that, whereas medica management succeeded in 6o per cent of the cases of bleeding ulcer seen after the first hemorrhage, onIy 15 per cent of the patients remained we11 on medica management when more than one hemorrhage had occurred. Recurrent hemorrhage therefore affords a sound indication for prompt surgica1 intervention.
126
A merican Journal of Surgery
CriIe and Crile,
Jr.-DuodenaI
In oIder patients and particuIarIy in women, conservative surgery gives exceIIent resuIts in the treatment of bIeeding ulcer. A gastroenterostomy or pyIoropIasty with IocaI excision of the uIcer wiI1 usuaIIy effect a permanent cure of the bIeeding. OccasionaIIy in younger men, with high free acid vaIues, and particuIarIy in those who have bIed a number of times in spite of medica management, it is perhaps wiser to resect the stomach, but it shouId be remembered that even extensive gastric resections do not give absoIute protection against the deveIopment of a margina uIcer. Extensive operations are contraindicated in the presence of recent bIeeding and it is wiser, when the patient is exsanguinated, to repIace the Iost bIood by transfusion, excise the ulcer, and perform a pyIoropIasty, as recommended by Judd.6 An uIcer which produces persistent pain that is unreIieved by skiIfu1 medica management, and is severe enough to interfere with the patient’s activities, thereby becomes a surgica1 probIem. As has been noted previously, approximateIy 60 per cent of the patients on whom conservative operations, such as pyIoropIasty or posterior gastroenterostomy, were performed for the reIief of pain obtained compIete and permanent reIief of symptoms. An additiona 18 per cent were partiaIIy reIieved and couId be kept comfortabIe provided they folIowed a reasonabIe medica regimen. The resuIts of conservative operations are not therefore so unsatisfactory, particuIarIy when we remember that 20 per cent of the patients having gastric resections continued to compIain of more or Iess severe gastric distress if they were not carefu1 in respect to their diet. In this series of seventy-two gastrothe incidence of known enterostomies, gastrojejuna1 uIcer has been onIy 1.4 per cent. When the increased mortaIity rate of gastric resection is taken into consideration, and when the incidence of gastrojejuna1 uIcer foIIowing gastroenterostomy is 0nIy 3 per cent in the Iarge series of gastroenterostomies that have been performed
UIcer
APRIL, 1938
at the Mayo Clinic,’ and when the wide experiences of such surgeons as Judd and BaIfour Ied them to conclude that from 85 to go per cent of the patients with duodena1 uIcers treated by conservative operations such as gastroenterostomy or pyIoropIasty were improved, we must weigh the probIem seriousIy before recommending more hazardous procedures for the treatment of an essentiaIIy benign disease. TrimbIe and Reeves8 report a series of 150 posterior gastroenterostomies performed at the Johns Hopkins HospitaI with a 2 per cent mortaIity rate. A carefu1 foIIow-up showed 74 per cent of these patients to be we11 and free of symptoms referabIe to uIcer. The incidence of margina uIcer was onIy 0.8 per cent. Strauss,g in discussing the post-operative course of forty-four patients subjected to gastric resection for duodena1 uIcer, reports the occurrence of one gastrojejuna1 uIcer and faiIure to reIieve the patients of gastrointestina1 symptoms in 16 per cent of the cases. When the mortaIity rate in gastric resections for peptic uicer is quoted at I I .8 per cent by surgeons of as wide experience in gastric surgery as MarshaII,‘O and when Waiters” states that the mortaIity foIIowing this operation in the hands of experienced surgeons is from 7 to 15 per cent, strong indications must exist before it can be recommended. In our opinion, gastric surgery for duodena uIcer shouId be avoided if possibIe. When necessary, a pyIoropIasty or a gastroenterostomy affords exceIIent chances for a permanent cure with a minimum risk. AI1 patients subjected to surgery shouId remain under medica supervision and shouId continue to consider themseIves as uIcer patients. If these measures fai1, resection of the stomach can stiI1 be performed. OnIy in the hands of surgeons of such ski11 and experience as Roscoe Graham,2 whose mortaIity rate in a Iarge series of gastric resections is 3 per cent, does so radica1 an operation seem to be justified in the treatment of a benign disease.
NEW SERIES VOL.XL, No.
I
CriIe and CriIe,
Jr.-DuodenaI
In a smaI1 series of carefuIIy seIected cases in the majority of which gastric operations had been performed previousIy for the reIief of symptoms of ulcer, Dr. CriIe, Sr. has denervated the adrenal gIands and severed the spIanchnic nerves. This procedure brings immediate reIief of the symptoms referabie to uIcer and in some instances has afforded remissions lasting throughout the period of foIIow-up and as Iong as six years. In other cases, however, the resuIts after the first year or two have been Iess satisfactory. The status of this probIem is not yet definiteIy settIed and it wiI1 remain for the future to teI1 whether or not surgicaI intervention in the sympathetic nervous system wiI1 provide a means of controIIing selected cases of uIcer that have not improved with medica treatment. Since a high strung temperment, overwork, and worry constitute the background upon which uIcer is generated in many cases, it is essential, in conjunction with surgery and medica management, therefore, that the patient be taught discipline and seIf-contro1 as a means of minimizing the background of nervous tension upon which peptic uIcer is generated. SUMMARY I.
Duodenal uIcer is essentiaIIy a medical probIem and surgery is indicated onIy for its compIications, i.e., obstruction, recurrent hemorrhage, perforation, and penetration with intractable pain. 2. Conservative operation such as pyIoropIasty with excision of the uIcer or gastroenterostomy have given good resuIts with a low mortality rate. 3. The mortality rate associated with gastric resection is approximateIy three times as great as that of the more conserva-
UIcer
American Journal 0i Surgery I 27
tive operations and the prospects of complete reIief of gastrointestina1 symptoms are not much greater than with the more conservative procedures. 4. In view of the relatively good resuIts obtainable by conservative surgery, we do not beIieve that more radica1 operations shouId generaIIy be appIied in the treatment of an essentiaIIy benign disease. 5. When duodena1 uIcer is compIicated by hemorrhage, obstruction, or perforation, the combination of conservative surgery and skiIfu1 medical management both before and after operation wiI1 offer more for the patient than either form of treatment aIone. REFERENCES I. GRAY, H. K. SurgicaI treatment of peptic uIcer and its complications. Illinois M. J., 71: 411-413 (May) 1937. 2. GRAHAM, ROSCOE, R. Surgeon’s responsibility in treatment of duodenal ulcer. Canad. M. A. J., 35: 263-268 (Sept.) 1936. 3. KIEFER, EVERETT D. Hemorrhage in peptic ulcer. Surg. Clin. Nortb America, 14: 1073-1083 (Oct.) 1934. 4. ALLEN, ARTHUR W., and BENEDICT, EDWARD B. Acute massive hemorrhage from duodenal uIcer. Ann. Surg., g8: 736-748 (Oct.) 1933. 5. LAHEY, FRANK H. Discussion, op. cit. 4. 6. JUDD, E. S., and HAZELTINE, M. E. Rest&s of operations for excision of uIcer of duodenum. Ann. Surg., 92: 563-573 (Oct.) 1930. 7. EUSTERMANN, GEORGE B., and BALFOUR, DONALD C. The Stomach and Duodenum. PhiIadeIphia, 1935. W. B. Saunders Co. 8. TRIMBLE, I. R., and REEVES, D. L. Surgical treatment of gastric and duodena1 uIcers. Bull. Johns Hopkins Hosp., 59: 35-59 (July) 1936. 9. STRAUSS, A. A., et. al. Physiologica and clinical study of patients after subtotal gastrectomy. Am. J. Digest. Dis. e”rNutrition, 4: 32-37 (March) 1937. IO. MARSHALL, S. F. Postoperative complications folIowing subtota1 gastrectomy. Surg. Clin. Nortb America, 17: 705-716 (June) 1937. I I. WALTERS, W. Operative treatment of gastric and duodena1 uIcer; physioIogic and pathoIogic principles influencing type of procedure. J. Michigan Med. Sot., 35: 491-496 (Aug.) 1936.
M.D.,
AND
GEORGE
CRILE,
JR., M.D.
CIeveIand Clinic CLEVELAND,
I
N rg22,35 per cent of the patients with duodena1 uIcer seen at the CIeveIand CIinic were subjected to surgica1 operations. In 1937 onIy 5 per cent of the patients with duodena1 uIcer required surgica1 treatment. In the past fifteen years, therefore, we have become seven times more conservative in recommending operative treatment for duodena1 uIcer. This trend toward the conservative management of duodena1 uIcer is the resuIt not onIy of the superior methods of medical management that the gastroenteroIogist now has at his disposal, but aIso of the experience gained in foIIowing more than 2600 patients with duodena1 uIcer, many of whom, especiaIIy in the earIier days, were subjected to surgica1 operations. An anaIysis of the results in IOO consecutive cases of duodena1 uIcer treated by surgery indicates that our growing conservatism and desire to manage these patients on a medica regimen is we11 justified. Yet we should Iike to emphasize again that certain of the compIications of duodena1 ulcer such as perforation, persistent or recurrent obstruction, and recurrent hemorrhage, demand surgica1 intervention and that the best interest of the patient wiI1 be served if surgery in these cases is not deIayed. ANALYSIS OF 100 CONSECUTIVE CASES OF DUODENAL ULCER TRFATED BY SURGERY The indications for operation in IOO consecutive cases of duodena1 uIcer treated by surgery are given in TabIe I. The operations performed for the reIief of these symptoms are shown in Table II. Seventy-four per cent of these patients were foIIowed for from six months to ten
OHIO TABLE LEADING
SYMPTOMS
I BEFORE
OPERATION
Per Cent 54
Pain.............................. Obstruction. Bleeding........................,, Acute perforation..
26 12
8
years after operation, an average foIIow-up period of forty-six and one-half months. TABLE OPERATIONS
II PERFORMED
Per Cent Posterior gastroenterostomy. . 72 Resection of stomach (posterior polya in the majority of cases). 14 Closure of perforated ulcer. 6 PyIoropIasty. . . 5 Posterior gastroenterostomy and plication of perforated ulcer.. . 2 Anterior gastroenterostomy. I RESULTS
FOLLOWING
POSTERIOR
GASTROENTEROSTOMY
As indicated in TabIe I, posterior gastroenterostomy was the operation of choice in seventy-two of the IOO cases. In this series, there were three hospita1 deaths, a mortality rate of 4.2 per cent. In sixteen cases, the gastroenterostomy was performed for obstruction. Fourteen, or 87.5 per cent, of these patients obtained compIete reIief of a11 symptoms referable to TABLE RESULTS
OF
POSTERIOR FOR
III GASTROENTEROSTOMY
OBSTRUCTION
Sixteen Cases (Post-Operative
Deaths Not IncIuded)
Result
Completely relieved. PartiaIIy relieved. No relief.. . TotaI........................
.
14
.
87.50 6.25 6.25
I I .I
16
)
Ioo
I24
American Journal of Surgery
CriIe and Crile,
Jr.-DuodenaI
uIcer or obstruction. One patient (6.2 per cent) obtained partiaI reIief, and one patient obtained no relief. (TabIe III.) The end resuIts of gastroenterostomy in thirty-three patients whose outstanding compIaint was pain were Iess satisfactory than when the Ieading symptom was obstruction. In 60.6 per cent of the cases, complete reIief of symptoms was obtained, but it shouId be noted that a few of the patients found it necessary to remain on a guarded diet in order to avoid a recurrence of symptoms. PartiaI reIief was obtained in 18.2 per cent, and 2 1.2 per cent failed to obtain any striking reIief of symptoms unIess they adhered to a rigid medical regimen. (TabIe IV.) TABLE Iv RESULTS OF POSTERIOR GASTROENTEROSTOMY FOR PAIN Thirty-three
Cases
(Post-Operative
Result
Completely relieved. ............ PartiaIly relieved. ............... No relief .......................
TotaI ........................
Deaths
ExcIuded)
Number of Cases
Per Cent of Total Cases
-I
20 6 7
-I
33
60.6 18.2 21.2 100
The results of gastroenterostomy for pain must therefore be cIassified as being good onIy in conjunction with dietary management of the uIcer. Operation aIone cannot be considered to effect compIete and permanent relief of pain in a11 cases. The results in the oIder patients were distinctIy better than in the younger, permanent reIief of symptoms being 20 per cent more common in patients over 45 years of age than in those under 45. In five cases, posterior gastroenterostomy was performed because of a history of recurrent hemorrhage from a duodena1 uIcer. Four of these five patients had no recurrence of the hemorrhage and in one case there was a recurrence of the bIeeding. (TabIe v.)
UIcer
APRIL, 1938
TABLE v RESULTS OF POSTERIOR GASTROENTEROSTOMY FOR BLEEDING Five Cases (Post-Operative Deaths
Not IncIuded)
I
I Number of Cases
I
Completely No relief..
relieved.
~~$~n~ Cases
I4 I (recurrence of hemorrhage)
80 20
The end resuIts of gastroenterostomy for obstruction, pain, and bIeeding are summarized in TabIes III, IV, and v. It is cIear from the foregoing data that the best resuIts folIowing posterior gastroenterostomy are obtained when obstruction is present. When gastroenterostomy is to be performed for pain or hemorrhage, it must be with the understanding that the patient wiI1 continue to foIIow a guarded diet and wiI1 consider the gastroenterostomy as an adjunct to medica management. It has been our experience, however, that ulcers which are intractabIe to medica therapy before operation wiI1 usuaIIy yieId readiIy to treatment after gastroenterostomy is performed. GASTRIC
RESECTION
The post-operative mortaIity rate from gastric resection has been approximateIy three times as great as that from gastroenterostomy. Gastric resection is therefore an operation which, in the absence of specia1 indications, shouId not be advised for a disease which is essentiaIIy benign. In addition, aIthough gastric resection effects a cure of the uIcer in the great majority of cases, it has been our experience that in some cases this procedure repIaces the symptoms of uIcer with other types of distress which may be equaIIy annoying to the patient. Thus, 20 per cent of the patients having gastric resections compIained of gastric symptoms comparabIe in severity to those produced by the uIcer which had been resected and in
NEW SERIES VOL. XL, No.
I
CriIe and CriIe,
Jr.-DuodenaI
one instance hemorrhage from a gastrojejunaI ulcer occurred. It is doubtIess a satisfaction to the surgeon to have cured the duodena1 uIcer, but the patient cannot enjoy this satisfaction if he continues to experience pain. Many of the patients whose stomachs had been resected were forced to foIIow a guarded diet in order to be free of symptoms and hence the postoperative course of the patients with gastric ahhough the uIcer may be resections, cured, may entail as much attention to diet and as much gastric distress as is reported to occur in patients subjected to more conservative procedures. The greater mortaIity rate associated with gastric resection shouId influence the decision, wherever possibIe, in favor of the more conservative measures. DISCUSSION
From the foregoing data, it is clear that gastric surgery, and particuIarIy the more radicaI and hence more dangerous types of gastric surgery, ahhough perhaps curing the uIcer, do not aIways resuIt in the compIete and permanent reIief of gastric distress. In addition, as Gray1 has stated, “Promiscuous resection of the stomach for duodena1 ulcer does not seem to be warranted. The risk of a fata outcome with this procedure is probabIy greater than is the possibihty of obtaining an unsatisfactory functiona result or a recurrent or anastomotic ulceration with the more conservative surgicaI measures.” For these we have become progressively reasons, more conservative in recommending radical surgery for patients with duodena1 uIcer. Although we now beIieve that, with careful medical management, over g5 per cent of the patients with duodena1 ulcer can carry on their norma activities in safety and comfort, there are certain complications of peptic uIcer which demand surgicaI intervention. The first of these is acute perforation. The perforation shouId be cIosed as soon as possibIe and no further surgery should be attempted at this time. In our experi-
UIcer
A merican Journal of Surgery
125
ence, the mortaIity rate foIIowing gastroenterostomy and cIosure of a perforated uIcer has been UnjustifiabIy high. We beIieve with Roscoe Graham2 that in the presence of a perforated uIcer the surgeon shouId “dea1 in the most simpIe manner onIy with the Iesion which creates the hazard to Iife.” Graham records thirty-six consecutive operations for perforated uIcer without a death. Pyloric obstruction may occur as the resuIt of inflammatory edema, spasm, or actuaI cicatricia1 stenosis secondary to a duodenal uIcer, and often wiII be compIeteIy reheved by skiIfu1 medica management with the patient at rest in the hospitaI for a few days to two weeks. If, however, no reIief is obtained or if the obstruction recurs, posterior gastroenterostomy wilI give prompt and permanent reIief with maximum safety. Obstructing duodena1 uIcers rareIy recur after gastroenterostomy. Hence, in cases with obstruction, resection of the ulcer or resection of the stomach are unnecessary and, in view of the increased mortaIity rate associated with these procedures, they are undesirable. The mortaIity rate in patients with bIeeding duodena1 uIcer treated conservativeIy is considerabIy higher than has been generaIIy recognized. The recent studies of Kiefer3 show that the mortaIity rate in this condition is approximateIy 5 per cent. As AIIen and Benedict4 have shown, this mortality rate increases with advancing age and with each succeeding hemorrhage. Thus in patients beyond middIe age who have previousIy had one or more hemorrhages, the case fataIity is higher than the post-operative mortaIity rate of a conservative operation for duodena1 uIcer. In the Lahey series,5 it has been observed that, whereas medica management succeeded in 6o per cent of the cases of bleeding ulcer seen after the first hemorrhage, onIy 15 per cent of the patients remained we11 on medica management when more than one hemorrhage had occurred. Recurrent hemorrhage therefore affords a sound indication for prompt surgica1 intervention.
126
A merican Journal of Surgery
CriIe and Crile,
Jr.-DuodenaI
In oIder patients and particuIarIy in women, conservative surgery gives exceIIent resuIts in the treatment of bIeeding ulcer. A gastroenterostomy or pyIoropIasty with IocaI excision of the uIcer wiI1 usuaIIy effect a permanent cure of the bIeeding. OccasionaIIy in younger men, with high free acid vaIues, and particuIarIy in those who have bIed a number of times in spite of medica management, it is perhaps wiser to resect the stomach, but it shouId be remembered that even extensive gastric resections do not give absoIute protection against the deveIopment of a margina uIcer. Extensive operations are contraindicated in the presence of recent bIeeding and it is wiser, when the patient is exsanguinated, to repIace the Iost bIood by transfusion, excise the ulcer, and perform a pyIoropIasty, as recommended by Judd.6 An uIcer which produces persistent pain that is unreIieved by skiIfu1 medica management, and is severe enough to interfere with the patient’s activities, thereby becomes a surgica1 probIem. As has been noted previously, approximateIy 60 per cent of the patients on whom conservative operations, such as pyIoropIasty or posterior gastroenterostomy, were performed for the reIief of pain obtained compIete and permanent reIief of symptoms. An additiona 18 per cent were partiaIIy reIieved and couId be kept comfortabIe provided they folIowed a reasonabIe medica regimen. The resuIts of conservative operations are not therefore so unsatisfactory, particuIarIy when we remember that 20 per cent of the patients having gastric resections continued to compIain of more or Iess severe gastric distress if they were not carefu1 in respect to their diet. In this series of seventy-two gastrothe incidence of known enterostomies, gastrojejuna1 uIcer has been onIy 1.4 per cent. When the increased mortaIity rate of gastric resection is taken into consideration, and when the incidence of gastrojejuna1 uIcer foIIowing gastroenterostomy is 0nIy 3 per cent in the Iarge series of gastroenterostomies that have been performed
UIcer
APRIL, 1938
at the Mayo Clinic,’ and when the wide experiences of such surgeons as Judd and BaIfour Ied them to conclude that from 85 to go per cent of the patients with duodena1 uIcers treated by conservative operations such as gastroenterostomy or pyIoropIasty were improved, we must weigh the probIem seriousIy before recommending more hazardous procedures for the treatment of an essentiaIIy benign disease. TrimbIe and Reeves8 report a series of 150 posterior gastroenterostomies performed at the Johns Hopkins HospitaI with a 2 per cent mortaIity rate. A carefu1 foIIow-up showed 74 per cent of these patients to be we11 and free of symptoms referabIe to uIcer. The incidence of margina uIcer was onIy 0.8 per cent. Strauss,g in discussing the post-operative course of forty-four patients subjected to gastric resection for duodena1 uIcer, reports the occurrence of one gastrojejuna1 uIcer and faiIure to reIieve the patients of gastrointestina1 symptoms in 16 per cent of the cases. When the mortaIity rate in gastric resections for peptic uicer is quoted at I I .8 per cent by surgeons of as wide experience in gastric surgery as MarshaII,‘O and when Waiters” states that the mortaIity foIIowing this operation in the hands of experienced surgeons is from 7 to 15 per cent, strong indications must exist before it can be recommended. In our opinion, gastric surgery for duodena uIcer shouId be avoided if possibIe. When necessary, a pyIoropIasty or a gastroenterostomy affords exceIIent chances for a permanent cure with a minimum risk. AI1 patients subjected to surgery shouId remain under medica supervision and shouId continue to consider themseIves as uIcer patients. If these measures fai1, resection of the stomach can stiI1 be performed. OnIy in the hands of surgeons of such ski11 and experience as Roscoe Graham,2 whose mortaIity rate in a Iarge series of gastric resections is 3 per cent, does so radica1 an operation seem to be justified in the treatment of a benign disease.
NEW SERIES VOL.XL, No.
I
CriIe and CriIe,
Jr.-DuodenaI
In a smaI1 series of carefuIIy seIected cases in the majority of which gastric operations had been performed previousIy for the reIief of symptoms of ulcer, Dr. CriIe, Sr. has denervated the adrenal gIands and severed the spIanchnic nerves. This procedure brings immediate reIief of the symptoms referabie to uIcer and in some instances has afforded remissions lasting throughout the period of foIIow-up and as Iong as six years. In other cases, however, the resuIts after the first year or two have been Iess satisfactory. The status of this probIem is not yet definiteIy settIed and it wiI1 remain for the future to teI1 whether or not surgicaI intervention in the sympathetic nervous system wiI1 provide a means of controIIing selected cases of uIcer that have not improved with medica treatment. Since a high strung temperment, overwork, and worry constitute the background upon which uIcer is generated in many cases, it is essential, in conjunction with surgery and medica management, therefore, that the patient be taught discipline and seIf-contro1 as a means of minimizing the background of nervous tension upon which peptic uIcer is generated. SUMMARY I.
Duodenal uIcer is essentiaIIy a medical probIem and surgery is indicated onIy for its compIications, i.e., obstruction, recurrent hemorrhage, perforation, and penetration with intractable pain. 2. Conservative operation such as pyIoropIasty with excision of the uIcer or gastroenterostomy have given good resuIts with a low mortality rate. 3. The mortality rate associated with gastric resection is approximateIy three times as great as that of the more conserva-
UIcer
American Journal 0i Surgery I 27
tive operations and the prospects of complete reIief of gastrointestina1 symptoms are not much greater than with the more conservative procedures. 4. In view of the relatively good resuIts obtainable by conservative surgery, we do not beIieve that more radica1 operations shouId generaIIy be appIied in the treatment of an essentiaIIy benign disease. 5. When duodena1 uIcer is compIicated by hemorrhage, obstruction, or perforation, the combination of conservative surgery and skiIfu1 medical management both before and after operation wiI1 offer more for the patient than either form of treatment aIone. REFERENCES I. GRAY, H. K. SurgicaI treatment of peptic uIcer and its complications. Illinois M. J., 71: 411-413 (May) 1937. 2. GRAHAM, ROSCOE, R. Surgeon’s responsibility in treatment of duodenal ulcer. Canad. M. A. J., 35: 263-268 (Sept.) 1936. 3. KIEFER, EVERETT D. Hemorrhage in peptic ulcer. Surg. Clin. Nortb America, 14: 1073-1083 (Oct.) 1934. 4. ALLEN, ARTHUR W., and BENEDICT, EDWARD B. Acute massive hemorrhage from duodenal uIcer. Ann. Surg., g8: 736-748 (Oct.) 1933. 5. LAHEY, FRANK H. Discussion, op. cit. 4. 6. JUDD, E. S., and HAZELTINE, M. E. Rest&s of operations for excision of uIcer of duodenum. Ann. Surg., 92: 563-573 (Oct.) 1930. 7. EUSTERMANN, GEORGE B., and BALFOUR, DONALD C. The Stomach and Duodenum. PhiIadeIphia, 1935. W. B. Saunders Co. 8. TRIMBLE, I. R., and REEVES, D. L. Surgical treatment of gastric and duodena1 uIcers. Bull. Johns Hopkins Hosp., 59: 35-59 (July) 1936. 9. STRAUSS, A. A., et. al. Physiologica and clinical study of patients after subtotal gastrectomy. Am. J. Digest. Dis. e”rNutrition, 4: 32-37 (March) 1937. IO. MARSHALL, S. F. Postoperative complications folIowing subtota1 gastrectomy. Surg. Clin. Nortb America, 17: 705-716 (June) 1937. I I. WALTERS, W. Operative treatment of gastric and duodena1 uIcer; physioIogic and pathoIogic principles influencing type of procedure. J. Michigan Med. Sot., 35: 491-496 (Aug.) 1936.