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Indications for the Surgical Treatment of Peptic Ulcer
Indications for the Surgical Treatment . of Peptic Ulcer GORDON W. RALEIGH, M.D. *
"Healing is a matter of time, but it is sometimes also a matter of opportunity"-HIPPOCRATES.
THE opportunity to benefit an ulcer patient by means of surgical intervention is provided, as any junior medical student will tell you, when obstruction, intractable distress, hemorrhage or perforation dominates the clinical situation. A more sophisticated intern will inform you that failure of medical management is the indication for surgery. These hoary principles are simple, concise and pleasant to contemplate. While they may serve some obscure didactic purpose, they are hardly useful in determining the management of the individual situation. Veterans in the hand-to-hand struggle of clinical practice have long since recognized the unique problem faced with each individual patient. Each of us would welcome a set of rules to go by, and, could we formulate this set of rules for you and for ourselves, epoch-making progress would have been accomplished. Not only have we no such guide to offer, we doubt that any such system will ever be forthcoming. Individualization will remain the essence of the problem, and an ability to correlate the facts and synthesize the total management will remain the priceless ingredient that distinguishes successful doctors. We offer this clinic, then, only to re-emphasize some of the general problems and to indicate our feeling regarding some of the specific facets of these problems. It is generally stated that 85 per cent of peptic ulcer cases are am~n able to medical management. We will go further and state that more than 50 per cent of all instances of peptic ulceration never come to the attention of a physician. Of those that do come to our attention, some 85 per cent can be managed best without operative intervention. Of this number, in passing, perhaps one-half tax our capacities in achieving adequate management. The remaining half would do as well if they received no particular medical attention. This is because of the well rec-
* Associate
in Medicine, Northwestern University Medical School, Chicago.
77
78
Gordon W. Raleigh
ognized importance of life situation in the genesis and perpetuation of peptic ulcer and the strong survival force which enables most individuals to re-establish workable life situations. These quasi-statistical considerations cannot be concluded without reminding ourselves of the small but definite number of ulcer patients who would have been better off had they never consulted a physician-for we must certainly admit to those instances of iatrogenic perpetuation and aggravation of peptic ulcer disease and its sequelae. With these precautions in mind, we need further only concern ourselves with that 10 to 20 per cent of encountered situations pertinent to this discussion. The opportunity to favor healing by surgical intervention is undoubtedly presented to the doctor by many patients in a variety of situations. One need hardly point out that controversy surrounds the selection of patient and situation. The importance of accurate selection lies in these inescapable facts: failure to operate at the optimum time may 'cost the patient his life, or will at least sentence him to needless disability; on the other hand there is an appreciable operative mortality and very often a more than just appreciable postoperative morbidity. Bearing the heavy responsibility implicit in these facts, we must arrive at our decision by consideration of three factors-the doctor, the patient, the situation. THE DOCTOR
Fortunate indeed is the patient having a doctor who thinks and acts like one. Most of us think like internists (or, probably worse, like gastroenterologists) or like surgeons. General men usually are inclined to the medical or surgical side. This professional bias not only colors the literature but greatly influences the approach to the individual patient. While it is only natural for one to favor the tools and methods of his own profession, in respect to any given situation there can be only one correct solution. Sincere attempts are being made by both physicians and surgeons to eradicate this unfortunate prejudice. Progress is indicated by t.he fact that many younger surgeons now are so conservative as to sometimes err in advising against surgical treatment while, in the same vein, many younger internists are prone to advise surgery prematurely. For these reasons we prefer to think of the management as operative or nonoperative rather than as medical or surgical. This avoids the implication that one form of therapy is carried out by the medical men and another form of therapy by the surgeons-that these are conflicting or independent schools of thought. Actually, of course, the over-all treatment is nonoperative and such nonoperative care must precede and follow any operative phase of the management. The adequacy of medical care is a measure of the adequacy of the physician, provided the patient can and will cooperate. If the failure of
Indications for Surgery in Peptic Ulcer
79
medical care is an indication for surgery, one must first be assured that such medical care includes all of the social, psychological, dietary and phaImacologic weapons at our command. The adequacy of available surgical personnel and facilities constitutes an important consideration in making the decision for operative treatment. While such personnel and facilities are available in numerous places in this country, not every surgeon nor every hospital is properly equipped, even though they are at present doing gastrointestinal surgery. We have not infrequently advised against surgery in situations where operative interference seemed like the better solution, when there was doubt as to the adequacy of the surgical team or its facilities. THE PATIENT
Emergency indications for surgery are not primarily influenced by patient factors to any more than the obvious extent, though decision as to the type of surgery performed may be largely predicated on the patient's background. Thus, for example, operation for acute perforation in a patient of ulcerogenic disposition and chronic disability will be extensive, probably a subtotal gastric resection, if feasible. Simpler procedures will be chosen in the acute and new case where a recognizable ulcer pattern is lacking. In the more leisurely elective situations, however, we are inclined to be influenced by the fundamental type of the patient. We are all familiar with those ectomorphic persons who are never able to develop any measure of equanimity, are usually unable to cooperate in a well rounded regimen of medical care for any length of time, are hyperactive and hyperacid and often subject to continuing distress and recurrent complications. Early surgery is looked on with favor as being the best solution to this problem. On the other hand, it is only with the greatest reluctance that we consider surgery in the case of those individuals who do not fit the ulcer pattern. Age is often overemphasized as a factor. We view surgical intervention in persons under 20 as an approach to be avoided in all but emergency situations, because ulcers in this age group are often of a transitory nature and the possibility of malignancy, regardless of the location of the ulcer, is almost nil. Above the age of 20 we are influenced very little by the chronological age of the patient. We have seen so many carcinomas in young adults that youth affords us little security in viewing gastric ulcers while sclerosis of vessels involved in the chronic inflammatory base of an ulcer is more important in the perpetuation of hemorrhage than is the age-influenced atherosclerotic process. Duration of the ulcer in the particular patient under consideration is closely related to the somatotypic and environmental factors previously mentioned. In the case of gastric ulceration, long known duration may
Gordon W. Raleigh
80 be the major deterrent of surgery. In every other situation, chronicity is a point in favor of surgical treatment. The presence of other diseases may be the deciding factor. Obviously, many patients will suffer from processes which absolutely contraindicate surgery. More difficult of evaluation are those instances in which concomitant disease processes materially increase the risk of surgery but do not absolutely contraindicate it. Here one is faced with the necessity of estimating the amended over-all risk and weighing it in the balance against the probable benefit of surgery. Such an infinite variety of combinations of circumstances exist in this respect that systematic discussion is impossible. In general, if there is a strong circumstantial indication for surgical treatment, we are inclined to accept rather great collateral risks. Thus, for example, in the face of an ulcerated gastric lesion that is quite likely malignant, we are not deterred by cardiovascular disease short of intractable congestive heart failure or recent myocardial infarction. A great number of special considerations involving the individual patient may arise. A man who has suffered one or two hemorrhages under fair control, who would usually be observed further under medical care, might properly be subjected to surgery if he were planning a long sojourn in, say, the interior of Africa. Again, the number of such special conditions, revolving about the patient, his attitudes and his activities, are legion and can only. be met as they arise. THE SITUATION
Location of PriInary Ulceration
Esophageal ulcers are not uncommon, particularly the acute variety complicating the peptic esophagitis of prolonged intubation. They are not treated surgically by election. Gastric ulcers are fundamentally related to duodenal ulcers only by certain histologic similarities and anatomic propinquity. They are all potentially ulcerated carcinomas and therefore present a problem that is quite different from that imposed by the duodenal ulcer. If there is any reasonable doubt as to the benignancy of the lesion it should be treated surgically. This means that, categorically, every ulcer that occurs in the stomach any place except on the lesser curvature and adjacent anterior and posterior walls should be approached surgically at once. A possible exception to this principle occurs when the ulcer has been known and followed radiographically over a long period of time. Some would also avoid immediate surgery at least when the ulcer is situated so high that the enhanced operative mortality, due to technical difficulty, will exceed the statistical probability of the lesion being malignant. We are unable
Indications for Surgery in Peptic Ulcer
81
to subscribe to the latter viewpoint since it draws statistical conclusions from heterologous probabilities which cannot be compared. Ulcers situated in the lesser curvature or adjacent anterior or posterior walls have a greater likelihood of being benign. These patients are tentatively subjected to medical management for a period of 30 days. Failure of immediate symptomatic improvement or hypochlorhydria suggest cancer strongly enough that we may not wait the contemplated period for radiographic healing to occur. While we are not at all influenced by the size of the crater we do feel that radiographic demonstration of alteration in the rugal pattern and relative inflexibility of the stomach wall favors the probability of cancer. Given these radiographic phenomena plus hypochlorhydria in an adult who has not experienced nearly complete relief of symptoms in a few days and in whom x-ray does not reveal complete healing in ten days, immediate surgical treatment is indicated. Lacking these supporting features, the patient is treated medically for the full 30 day period. Complete radiographic healing of the ulcer at the end of this time indicates further observation. Any suggestion of persistence of any part of the ulcer, confirmed by another x-ray study, renders immediate surgical intervention mandatory. Gastroscopy and techniques designed to obtain cells for study by the Papanicalaou method are without value. Ulcer occurring in a hiatus hernia is managed in the same fashion as any other gastric ulcer. Gastroduodenal ulceration may trap the unwary into a regimen appropriate to the care of the duodenal ulcer. It should be managed as gastric ulcer. Peptic ulcer of the duodenum is not fraught with the danger of malig. nancy. Surgery is rarely indicated in the management of this disease as will be detailed below. Ulceration of ectopic gastric tissue situated in Meckel's diverticulum is a mere curiosity. So-called Cushing's ulcer and Curling's ulcer are treated the same as any other cases of duodenal ulceration.
Bleeding Small hemorrhage, manifested by one or two tarry stools and no change in the blood picture, occurs frequently. It is most often not even drawn to the attention of the doctor unless the patient has had some prior experience and recognizes the significance of the black stool. Such bleeding is often due to superficial erosion and venous oozing rather than being due to arterial invasion. Not uncommonly this occurs in patients who are virtually asymptomatic. The unequivocal history of this manifestation, if coupled with other and more compelling criteria, favors the decision for surgical treatment only because it indicates chronicity. Acute and massive hemorrhage is not uncommonly the first indication
82
Gordon W. Raleigh
of peptic ulceration. In many cases it seems quite likely that the cause is acute, often superficial, peptic ulcer. Frequently no radiographic evidence can be demonstrated. Surgery is not indicated except in the most unusual circumstance of continued bleeding. Massive hemorrhage in the chronic peptic ulcer patient is another thing. This patient is more likely to give a recognizable ulcer history or, of course, may have been under care for known ulcer disease. The bleeding vessel, nearly always an artery, is often thickened and relatively unable to retract due to involvement in the chronic inflammatory process. Therefore hemorrhage is massive and prone to be continuous. Blood studies are of little help in evaluating the extent of the bleeding in the critical first 24 hours. Hematemesis usually indicates more massive hemorrhage as does tarry diarrhea. Shock parallels the extent of the hemorrhage. Most of these patients can be successfully managed without operative intervention. However, stubborn adherence to the medical regimen may eventuate in a situation in which, when the necessity for surgery becomes unequivocal the patient can no longer be put in optimal condition for the operation. Hypertension, arteriosclerosis, age over 50, gastric location of the ulcer (if known), c~ronicity, reduction of hematocrit to 25 per cent or less are all generally stated criteria favoring the surgical approach. Actually the decision to operate is most often made in the first 24 hours, before hemodilution is complete, so that the hematocrit is relatively lacking in accuracy or value. The other factors all revolve around the likelihood of the hemorrhage to cease spontaneously. The most important criterion resides in the determination of whether bleeding continues or has stopped because surgery provides the only means of arresting continued hemorrhage. While this cannot be determined directly, it can be estimated with some accuracy by the patient's ability to maintain circulatory stability. Provided external evidence of continued bleeding has ceased and provided there are no other compelling indications or contraindications for surgery, our decision is based on the ability of the patient to maintain circulatory stability with an infusion of 500 ml. of whole blood in each eight hour period. Decreasing blood pressure and increasing tachycardia under these circumstances are evidences of continued bleeding. The persistence of this situation into the second eight hour period clearly indicates the necessity for immediate operative treatment. Earlier surgery is mandatory if more blood and, perhaps, norepinephrine are required to maintain the blood pressure. Similarly, recurrent hematemesis or diarrhea are compelling evidences of continued bleeding regardless of other indications. Profound shock, evidence of exsanguinating hemorrhage, does not necessarily mean that bleeding continues. However, if the patient has not been neglected, it is unlikely that this situation will obtain unless the bleeding is intractable. Here again, surgery is indicated as soon as feasible.
Indications for Surgery in Peptic Ulcer
83
Recurrent bleeding, whether minor or massive, favors the decision to operate. This is particularly true of ulcers situated on the posterior duodenal wall vis-a-vis important arteries. It usually is accompanied by other evidences of intractability such as outlet obstruction, demonstrable ulceration and deformity, and persistent distress. As such it is only one of a battery of evidences that this patient can not or will not cooperate in the medical regimen. In this situation, even after five or six bleeding episodes, we are inclined to hope that the current one is the last, that the inconvenience and cost will persuade the patient to make the necessary compromises with his disease. Such is a forlorn hope. Recurrent bleeding coupled with other evidences of chronicity, occurring in the ulcerogenic type of person, and in the absence of important contraindication, clearly underscores the need for surgical intervention. Perforation
Acute perforation into the greater omental bursa not uncommonly occurs as the first indication of peptic ulcer. If such be the case, or if this accident only culminates a long recognized process, the treatment is operative. Immediate surgery in most cases will be directed toward simple closure of the perforation. In the case of longer existing ulcer disease, often with other complications known, a more definitive operation such as subtotal resection should be performed if the patient's condition allows. While it is well known that nonoperative management from the outset, supported by antibiotic therapy, frequently succeeds, we feel that the surgical approach is preferable. If, however, the patient is first seen more than 24 hours after the acute episode and there is good evidence of localization of the process, particularly if no intraperitoneal gas is demonstrated, the management should be nonoperative. A history of previous perforation favors the elective decision for surgical treatment of chronic, intractable peptic ulcer disease. If the clinical evidences of acute perforation are accompanied by rapid respiration and subcutaneous emphysema, perforation into the mediastinum is probable and immediate transthoracic surgical approach is indicated. Inadvertent perforation of the stoIIlach wall with the gastroscope or stomach tube must be treated surgically if the perforation is known to have occurred through a pathological area; otherwise, nonoperative management is indicated. Perforation sometimes complicates hemorrhage, usually within 24 hours of its onset. Conversely, hemorrhage may complicate perforation, more often about a week after the episode. In either event, the indications for operative treatment are the same as for either process occurring by itself.
84
Gordon W. Raleigh
Penetration
Forme fruste perforation into the retroduodenal tissues, when it occurs, is an accompaniment, almost invariably, of the chronic intractable ulcer syndrome and will be discussed in connection with that situation. Obstruction
Impairment of gastric emptying may be due to pylorospasm, local edema, cicatricial stenosis or some combination of these processes. Pylorospasm and edema cause relatively minor functional impairment and, if present by themselves, always respond to the regimen that favors repair of the actual ulceration. Cicatrix formation is a nearly constant corollary of chronicity, in the case of duodenal ulcers particularly. As such it is usually part of the syndrome of intractability. It is irreversible and can be adequately estimated only if the medical regimen can rid the patient of his ulcer and the reversible associated pylorospasm and contiguous edema. Such stenosis favors the decision for surgical relief. Intractable Distress
The syndrome of intractability rarely occurs in any but the typical ulcerogenic individual. There is usually abdominal pain of some degree, often with back pain consequent upon penetration into the pancreas. Outlet obstruction due to pylorospasm, edema and progressive cicatrix formation is associated with continuous, even over-night, secretion of highly acid gastric juice. There is probably no normal duodenal-gastric reflux. Anorexia, even nausea, and consequent malnutrition are familiar accompaniments of this situation. Single or recurrent hemorrhages and perforation are not an uncommon feature. The great majority of these patients could be managed nonoperatively. Knowing this we are inclined to cling rather stubbornly to the medical regimen and, consequently, the patient is often subjected to years of distress and the risk of emergency complication. Actually, rather than the disease, it is usually the patient who is intractable. If the physician or surgeon is satisfied that the best medical management possible for this particular person has been achieved, over a period of two years, and the syndrome still exists, this patient should have the benefit of surgical treatment. Sequelae of Previous Surgery
The so-called dumping syndrome and the closely related hypoglycemic syndrome are not amenable to surgical revision. Intractable malnutrition is a common and distressing consequence of operative treatment. When this is due to inadequate intake of food,
Indications for Surgery in Peptic Ulcer
85
psychological and environmental factors may be the major cause. Persistent distress due to stomal ulceration or fear of dumping and hypoglycemic symptoms may be deterrents of adequate food intake. If marginal, gastrojejunal or jejunal ulceration is present, or if a malfunctioning stoma can be consistently demonstrated by x-ray, surgical treatment is necessary. Digestive failure and absorptive failure may conduce to malnutrition independently of anorexia or unpleasant symptoms. If careful studies of fecal chemistry demonstrate failure of digestion or failure of absorption or both, a fistulous shunt is to be strongly suspected and every effort made to demonstrate this complication. The commonest intestinal shunt is the gastrojejunocolic fistula, often in association with gastrojejunal ulceration. Of rare occurrence but definitely to be considered in each case is inadvertent gastro-ileostomy. In either event, it is impossible to rehabilitate the patient until surgical revision has been accomplished. Where none of these mechanisms can be demonstrated, one is justified in considering the possibility of a redundant duodenal-jejunal segment and subjecting the carefully selected patient to surgical correction. 636 Church Street Evanston, Illinois
"Healing is a matter of time, but it is sometimes also a matter of opportunity"-HIPPOCRATES.
THE opportunity to benefit an ulcer patient by means of surgical intervention is provided, as any junior medical student will tell you, when obstruction, intractable distress, hemorrhage or perforation dominates the clinical situation. A more sophisticated intern will inform you that failure of medical management is the indication for surgery. These hoary principles are simple, concise and pleasant to contemplate. While they may serve some obscure didactic purpose, they are hardly useful in determining the management of the individual situation. Veterans in the hand-to-hand struggle of clinical practice have long since recognized the unique problem faced with each individual patient. Each of us would welcome a set of rules to go by, and, could we formulate this set of rules for you and for ourselves, epoch-making progress would have been accomplished. Not only have we no such guide to offer, we doubt that any such system will ever be forthcoming. Individualization will remain the essence of the problem, and an ability to correlate the facts and synthesize the total management will remain the priceless ingredient that distinguishes successful doctors. We offer this clinic, then, only to re-emphasize some of the general problems and to indicate our feeling regarding some of the specific facets of these problems. It is generally stated that 85 per cent of peptic ulcer cases are am~n able to medical management. We will go further and state that more than 50 per cent of all instances of peptic ulceration never come to the attention of a physician. Of those that do come to our attention, some 85 per cent can be managed best without operative intervention. Of this number, in passing, perhaps one-half tax our capacities in achieving adequate management. The remaining half would do as well if they received no particular medical attention. This is because of the well rec-
* Associate
in Medicine, Northwestern University Medical School, Chicago.
77
78
Gordon W. Raleigh
ognized importance of life situation in the genesis and perpetuation of peptic ulcer and the strong survival force which enables most individuals to re-establish workable life situations. These quasi-statistical considerations cannot be concluded without reminding ourselves of the small but definite number of ulcer patients who would have been better off had they never consulted a physician-for we must certainly admit to those instances of iatrogenic perpetuation and aggravation of peptic ulcer disease and its sequelae. With these precautions in mind, we need further only concern ourselves with that 10 to 20 per cent of encountered situations pertinent to this discussion. The opportunity to favor healing by surgical intervention is undoubtedly presented to the doctor by many patients in a variety of situations. One need hardly point out that controversy surrounds the selection of patient and situation. The importance of accurate selection lies in these inescapable facts: failure to operate at the optimum time may 'cost the patient his life, or will at least sentence him to needless disability; on the other hand there is an appreciable operative mortality and very often a more than just appreciable postoperative morbidity. Bearing the heavy responsibility implicit in these facts, we must arrive at our decision by consideration of three factors-the doctor, the patient, the situation. THE DOCTOR
Fortunate indeed is the patient having a doctor who thinks and acts like one. Most of us think like internists (or, probably worse, like gastroenterologists) or like surgeons. General men usually are inclined to the medical or surgical side. This professional bias not only colors the literature but greatly influences the approach to the individual patient. While it is only natural for one to favor the tools and methods of his own profession, in respect to any given situation there can be only one correct solution. Sincere attempts are being made by both physicians and surgeons to eradicate this unfortunate prejudice. Progress is indicated by t.he fact that many younger surgeons now are so conservative as to sometimes err in advising against surgical treatment while, in the same vein, many younger internists are prone to advise surgery prematurely. For these reasons we prefer to think of the management as operative or nonoperative rather than as medical or surgical. This avoids the implication that one form of therapy is carried out by the medical men and another form of therapy by the surgeons-that these are conflicting or independent schools of thought. Actually, of course, the over-all treatment is nonoperative and such nonoperative care must precede and follow any operative phase of the management. The adequacy of medical care is a measure of the adequacy of the physician, provided the patient can and will cooperate. If the failure of
Indications for Surgery in Peptic Ulcer
79
medical care is an indication for surgery, one must first be assured that such medical care includes all of the social, psychological, dietary and phaImacologic weapons at our command. The adequacy of available surgical personnel and facilities constitutes an important consideration in making the decision for operative treatment. While such personnel and facilities are available in numerous places in this country, not every surgeon nor every hospital is properly equipped, even though they are at present doing gastrointestinal surgery. We have not infrequently advised against surgery in situations where operative interference seemed like the better solution, when there was doubt as to the adequacy of the surgical team or its facilities. THE PATIENT
Emergency indications for surgery are not primarily influenced by patient factors to any more than the obvious extent, though decision as to the type of surgery performed may be largely predicated on the patient's background. Thus, for example, operation for acute perforation in a patient of ulcerogenic disposition and chronic disability will be extensive, probably a subtotal gastric resection, if feasible. Simpler procedures will be chosen in the acute and new case where a recognizable ulcer pattern is lacking. In the more leisurely elective situations, however, we are inclined to be influenced by the fundamental type of the patient. We are all familiar with those ectomorphic persons who are never able to develop any measure of equanimity, are usually unable to cooperate in a well rounded regimen of medical care for any length of time, are hyperactive and hyperacid and often subject to continuing distress and recurrent complications. Early surgery is looked on with favor as being the best solution to this problem. On the other hand, it is only with the greatest reluctance that we consider surgery in the case of those individuals who do not fit the ulcer pattern. Age is often overemphasized as a factor. We view surgical intervention in persons under 20 as an approach to be avoided in all but emergency situations, because ulcers in this age group are often of a transitory nature and the possibility of malignancy, regardless of the location of the ulcer, is almost nil. Above the age of 20 we are influenced very little by the chronological age of the patient. We have seen so many carcinomas in young adults that youth affords us little security in viewing gastric ulcers while sclerosis of vessels involved in the chronic inflammatory base of an ulcer is more important in the perpetuation of hemorrhage than is the age-influenced atherosclerotic process. Duration of the ulcer in the particular patient under consideration is closely related to the somatotypic and environmental factors previously mentioned. In the case of gastric ulceration, long known duration may
Gordon W. Raleigh
80 be the major deterrent of surgery. In every other situation, chronicity is a point in favor of surgical treatment. The presence of other diseases may be the deciding factor. Obviously, many patients will suffer from processes which absolutely contraindicate surgery. More difficult of evaluation are those instances in which concomitant disease processes materially increase the risk of surgery but do not absolutely contraindicate it. Here one is faced with the necessity of estimating the amended over-all risk and weighing it in the balance against the probable benefit of surgery. Such an infinite variety of combinations of circumstances exist in this respect that systematic discussion is impossible. In general, if there is a strong circumstantial indication for surgical treatment, we are inclined to accept rather great collateral risks. Thus, for example, in the face of an ulcerated gastric lesion that is quite likely malignant, we are not deterred by cardiovascular disease short of intractable congestive heart failure or recent myocardial infarction. A great number of special considerations involving the individual patient may arise. A man who has suffered one or two hemorrhages under fair control, who would usually be observed further under medical care, might properly be subjected to surgery if he were planning a long sojourn in, say, the interior of Africa. Again, the number of such special conditions, revolving about the patient, his attitudes and his activities, are legion and can only. be met as they arise. THE SITUATION
Location of PriInary Ulceration
Esophageal ulcers are not uncommon, particularly the acute variety complicating the peptic esophagitis of prolonged intubation. They are not treated surgically by election. Gastric ulcers are fundamentally related to duodenal ulcers only by certain histologic similarities and anatomic propinquity. They are all potentially ulcerated carcinomas and therefore present a problem that is quite different from that imposed by the duodenal ulcer. If there is any reasonable doubt as to the benignancy of the lesion it should be treated surgically. This means that, categorically, every ulcer that occurs in the stomach any place except on the lesser curvature and adjacent anterior and posterior walls should be approached surgically at once. A possible exception to this principle occurs when the ulcer has been known and followed radiographically over a long period of time. Some would also avoid immediate surgery at least when the ulcer is situated so high that the enhanced operative mortality, due to technical difficulty, will exceed the statistical probability of the lesion being malignant. We are unable
Indications for Surgery in Peptic Ulcer
81
to subscribe to the latter viewpoint since it draws statistical conclusions from heterologous probabilities which cannot be compared. Ulcers situated in the lesser curvature or adjacent anterior or posterior walls have a greater likelihood of being benign. These patients are tentatively subjected to medical management for a period of 30 days. Failure of immediate symptomatic improvement or hypochlorhydria suggest cancer strongly enough that we may not wait the contemplated period for radiographic healing to occur. While we are not at all influenced by the size of the crater we do feel that radiographic demonstration of alteration in the rugal pattern and relative inflexibility of the stomach wall favors the probability of cancer. Given these radiographic phenomena plus hypochlorhydria in an adult who has not experienced nearly complete relief of symptoms in a few days and in whom x-ray does not reveal complete healing in ten days, immediate surgical treatment is indicated. Lacking these supporting features, the patient is treated medically for the full 30 day period. Complete radiographic healing of the ulcer at the end of this time indicates further observation. Any suggestion of persistence of any part of the ulcer, confirmed by another x-ray study, renders immediate surgical intervention mandatory. Gastroscopy and techniques designed to obtain cells for study by the Papanicalaou method are without value. Ulcer occurring in a hiatus hernia is managed in the same fashion as any other gastric ulcer. Gastroduodenal ulceration may trap the unwary into a regimen appropriate to the care of the duodenal ulcer. It should be managed as gastric ulcer. Peptic ulcer of the duodenum is not fraught with the danger of malig. nancy. Surgery is rarely indicated in the management of this disease as will be detailed below. Ulceration of ectopic gastric tissue situated in Meckel's diverticulum is a mere curiosity. So-called Cushing's ulcer and Curling's ulcer are treated the same as any other cases of duodenal ulceration.
Bleeding Small hemorrhage, manifested by one or two tarry stools and no change in the blood picture, occurs frequently. It is most often not even drawn to the attention of the doctor unless the patient has had some prior experience and recognizes the significance of the black stool. Such bleeding is often due to superficial erosion and venous oozing rather than being due to arterial invasion. Not uncommonly this occurs in patients who are virtually asymptomatic. The unequivocal history of this manifestation, if coupled with other and more compelling criteria, favors the decision for surgical treatment only because it indicates chronicity. Acute and massive hemorrhage is not uncommonly the first indication
82
Gordon W. Raleigh
of peptic ulceration. In many cases it seems quite likely that the cause is acute, often superficial, peptic ulcer. Frequently no radiographic evidence can be demonstrated. Surgery is not indicated except in the most unusual circumstance of continued bleeding. Massive hemorrhage in the chronic peptic ulcer patient is another thing. This patient is more likely to give a recognizable ulcer history or, of course, may have been under care for known ulcer disease. The bleeding vessel, nearly always an artery, is often thickened and relatively unable to retract due to involvement in the chronic inflammatory process. Therefore hemorrhage is massive and prone to be continuous. Blood studies are of little help in evaluating the extent of the bleeding in the critical first 24 hours. Hematemesis usually indicates more massive hemorrhage as does tarry diarrhea. Shock parallels the extent of the hemorrhage. Most of these patients can be successfully managed without operative intervention. However, stubborn adherence to the medical regimen may eventuate in a situation in which, when the necessity for surgery becomes unequivocal the patient can no longer be put in optimal condition for the operation. Hypertension, arteriosclerosis, age over 50, gastric location of the ulcer (if known), c~ronicity, reduction of hematocrit to 25 per cent or less are all generally stated criteria favoring the surgical approach. Actually the decision to operate is most often made in the first 24 hours, before hemodilution is complete, so that the hematocrit is relatively lacking in accuracy or value. The other factors all revolve around the likelihood of the hemorrhage to cease spontaneously. The most important criterion resides in the determination of whether bleeding continues or has stopped because surgery provides the only means of arresting continued hemorrhage. While this cannot be determined directly, it can be estimated with some accuracy by the patient's ability to maintain circulatory stability. Provided external evidence of continued bleeding has ceased and provided there are no other compelling indications or contraindications for surgery, our decision is based on the ability of the patient to maintain circulatory stability with an infusion of 500 ml. of whole blood in each eight hour period. Decreasing blood pressure and increasing tachycardia under these circumstances are evidences of continued bleeding. The persistence of this situation into the second eight hour period clearly indicates the necessity for immediate operative treatment. Earlier surgery is mandatory if more blood and, perhaps, norepinephrine are required to maintain the blood pressure. Similarly, recurrent hematemesis or diarrhea are compelling evidences of continued bleeding regardless of other indications. Profound shock, evidence of exsanguinating hemorrhage, does not necessarily mean that bleeding continues. However, if the patient has not been neglected, it is unlikely that this situation will obtain unless the bleeding is intractable. Here again, surgery is indicated as soon as feasible.
Indications for Surgery in Peptic Ulcer
83
Recurrent bleeding, whether minor or massive, favors the decision to operate. This is particularly true of ulcers situated on the posterior duodenal wall vis-a-vis important arteries. It usually is accompanied by other evidences of intractability such as outlet obstruction, demonstrable ulceration and deformity, and persistent distress. As such it is only one of a battery of evidences that this patient can not or will not cooperate in the medical regimen. In this situation, even after five or six bleeding episodes, we are inclined to hope that the current one is the last, that the inconvenience and cost will persuade the patient to make the necessary compromises with his disease. Such is a forlorn hope. Recurrent bleeding coupled with other evidences of chronicity, occurring in the ulcerogenic type of person, and in the absence of important contraindication, clearly underscores the need for surgical intervention. Perforation
Acute perforation into the greater omental bursa not uncommonly occurs as the first indication of peptic ulcer. If such be the case, or if this accident only culminates a long recognized process, the treatment is operative. Immediate surgery in most cases will be directed toward simple closure of the perforation. In the case of longer existing ulcer disease, often with other complications known, a more definitive operation such as subtotal resection should be performed if the patient's condition allows. While it is well known that nonoperative management from the outset, supported by antibiotic therapy, frequently succeeds, we feel that the surgical approach is preferable. If, however, the patient is first seen more than 24 hours after the acute episode and there is good evidence of localization of the process, particularly if no intraperitoneal gas is demonstrated, the management should be nonoperative. A history of previous perforation favors the elective decision for surgical treatment of chronic, intractable peptic ulcer disease. If the clinical evidences of acute perforation are accompanied by rapid respiration and subcutaneous emphysema, perforation into the mediastinum is probable and immediate transthoracic surgical approach is indicated. Inadvertent perforation of the stoIIlach wall with the gastroscope or stomach tube must be treated surgically if the perforation is known to have occurred through a pathological area; otherwise, nonoperative management is indicated. Perforation sometimes complicates hemorrhage, usually within 24 hours of its onset. Conversely, hemorrhage may complicate perforation, more often about a week after the episode. In either event, the indications for operative treatment are the same as for either process occurring by itself.
84
Gordon W. Raleigh
Penetration
Forme fruste perforation into the retroduodenal tissues, when it occurs, is an accompaniment, almost invariably, of the chronic intractable ulcer syndrome and will be discussed in connection with that situation. Obstruction
Impairment of gastric emptying may be due to pylorospasm, local edema, cicatricial stenosis or some combination of these processes. Pylorospasm and edema cause relatively minor functional impairment and, if present by themselves, always respond to the regimen that favors repair of the actual ulceration. Cicatrix formation is a nearly constant corollary of chronicity, in the case of duodenal ulcers particularly. As such it is usually part of the syndrome of intractability. It is irreversible and can be adequately estimated only if the medical regimen can rid the patient of his ulcer and the reversible associated pylorospasm and contiguous edema. Such stenosis favors the decision for surgical relief. Intractable Distress
The syndrome of intractability rarely occurs in any but the typical ulcerogenic individual. There is usually abdominal pain of some degree, often with back pain consequent upon penetration into the pancreas. Outlet obstruction due to pylorospasm, edema and progressive cicatrix formation is associated with continuous, even over-night, secretion of highly acid gastric juice. There is probably no normal duodenal-gastric reflux. Anorexia, even nausea, and consequent malnutrition are familiar accompaniments of this situation. Single or recurrent hemorrhages and perforation are not an uncommon feature. The great majority of these patients could be managed nonoperatively. Knowing this we are inclined to cling rather stubbornly to the medical regimen and, consequently, the patient is often subjected to years of distress and the risk of emergency complication. Actually, rather than the disease, it is usually the patient who is intractable. If the physician or surgeon is satisfied that the best medical management possible for this particular person has been achieved, over a period of two years, and the syndrome still exists, this patient should have the benefit of surgical treatment. Sequelae of Previous Surgery
The so-called dumping syndrome and the closely related hypoglycemic syndrome are not amenable to surgical revision. Intractable malnutrition is a common and distressing consequence of operative treatment. When this is due to inadequate intake of food,
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psychological and environmental factors may be the major cause. Persistent distress due to stomal ulceration or fear of dumping and hypoglycemic symptoms may be deterrents of adequate food intake. If marginal, gastrojejunal or jejunal ulceration is present, or if a malfunctioning stoma can be consistently demonstrated by x-ray, surgical treatment is necessary. Digestive failure and absorptive failure may conduce to malnutrition independently of anorexia or unpleasant symptoms. If careful studies of fecal chemistry demonstrate failure of digestion or failure of absorption or both, a fistulous shunt is to be strongly suspected and every effort made to demonstrate this complication. The commonest intestinal shunt is the gastrojejunocolic fistula, often in association with gastrojejunal ulceration. Of rare occurrence but definitely to be considered in each case is inadvertent gastro-ileostomy. In either event, it is impossible to rehabilitate the patient until surgical revision has been accomplished. Where none of these mechanisms can be demonstrated, one is justified in considering the possibility of a redundant duodenal-jejunal segment and subjecting the carefully selected patient to surgical correction. 636 Church Street Evanston, Illinois