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Perforation of an Ischemic Proximal Gastric Remnant Following Gastric Resection
Perforation of an Ischemic Proximal Gastric Remnant Following Gastric Resection J. E. STRODE, M.D.*
It is the belief of most surgeons that the blood supply to the stomach is so ample that the danger of ischemia need not be considered when doing a gastric resection. Undoubtedly this is the case unless the blood supply is anomalous or the remaining vessels have become occluded by atherosclerotic changes. Brown and Derr 1 made a study of the blood supply of the human stomach, using the injection technique in cadavers, and found complete filling of all the intramural vessels by injection of any one of the four major arteries with all other extramural vessels ligated. Fairly complete filling occurred after injection of one short gastric artery with all others ligated. Somervell 7 reported over 400 patients with duodenal ulcers in whom four fifths of the branches of the major arteries to the stomach were ligated without ensuing necrosis. Rutter 6 in 1953 reported what was apparently the first case of ischemia of the remaining stomach after gastric resection, for he was unable to find any other references to this condition after carefully scanning the literature of the previous 20 years. Over the ensuing years an occasional case has been reported. Thompson9 in 1963 described four cases encountered at the University of Michigan Medical Center and said that up to that time only 12 other cases had been recorded in the world literature. No doubt many cases have occurred that have not found their way into the medical literature. Spencer,8 in personal communications with three surgeons who had had extensive experience with gastric surgery, found that each had seen two cases, and in five of the six the left gastric artery had been ligated and the spleen had been removed. Harkins 3 stated that in a series of 500 subtotal gastrectomies he had seen two instances of the "blue stomach syndrome" after division of the left gastric artery and all of the vasa brevia. One patient had no difficulty; *Department of General Surgery, Straub Clinic, Honolulu, Hawaii
Surgical Clinics of North America- Vol. 50, No. 2, April, 1970
301
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the other, who was 81 years old, developed a fatal anastomotic leak, but no necrosis was noted at autopsy. To explain more clearly the problem of ischemia of the remaining portion of the stomach after subtotal gastric resection, a brief review of the arterial supply to the proximal area of this organ seems advisable. Figure 1 demonstrates the arterial supply as normally encountered in the stomach, and Figure 2 shows the blood supply to the proximal stomach after the usual high gastric resection without removal of the spleen. The major arterial supply to the stomach arises from the celiac axis. The lesser curvature of the stomach is supplied by the right and left gastric arteries and the gastroduodenal and splenic arteries. The short gastric arteries, or the vasa brevia, arise from the splenic artery just before it divides into its terminal branches. The left phrenic artery arises from the aorta, or at times from the common trunk of the celiac artery, and supplies blood to the lower esophagus and adjacent stomach. Esophageal arteries arise directly from the aorta and the lower ones anastomose with the ascending esophageal branches of the phrenic and gastric arteries below. In the usual procedure of performing a high gastric resection the left gastric artery is ligated at its origin, and if the spleen is left in place there should be ample blood supply to the remaining stomach through the short gastric branches of the splenic, the esophageal and the inferior
L. phrenic a.-
R.gastric a.
''
'
''
'
gastroep1olo1c
1.
Figure 1. Normal blood supply to the stomach and lower esophagus.
PERFORATION OF AN ISCHEMIC PROXIMAL GASTRIC REMNANT
303
L.gastric
Figure 2. Blood supply to the remaining stomach after the usual gastric resection in which the spleen is not removed.
phrenic arteries (Fig. 2). If the spleen is removed, the blood supply is then dependent upon the esophageal and phrenic arteries. Many high gastric resections have been done, with these vessels alone remaining, without compromise to the circulation of the gastric remnant. One would be more certain of an adequate blood supply, however, if the left gastric arteries were divided beyond the ascending branch that extends to the gastroesophageal area. The importance of these short gastric vessels is emphasized in Thompson's report 9 of a 90 per cent gastric resection for a benign high gastric ulcer in which the spleen was not removed, thus preserving the short gastric arteries. Hemorrhage a week later necessitated ligation of the splenic artery and removal of the spleen. The gastric pouch and anastomosis were intact at that time. The patient died 1 week later, and autopsy showed ischemic necrosis of the stomach remnant. At times it has been noted that the blood supply to the left lobe of the liver arises from the left gastric artery. Friesen 2 has noted this occurrence in several patients coming to surgery, and in one instance in which this was not recognized and the left gastric artery was ligated proximal to the origin of the left hepatic artery, death occurred and was attributed to necrosis of the left lobe of the liver. CASE REPORT. A white man, aged 57, was operated upon on September 10 for a large penetrating ulcer of the upper lesser curvature of the stomach. At operation the lesion appeared to be malignant, but was later found to be benign. It had penetrated into the distal portion of the pancreas. A fairly radical resection was done, and the lymph nodes were cleaned out along the lesser curvature of the stomach as high as the esophagus. Most of the omentum and about 75 per cent of the stomach were removed, but the spleen was not. The left gastric artery was ligated and severed at its origin at the celiac axis. It was noted at the time of the
304
J, E.
STRODE
operation that the color of the remaining stomach was bluer than usual and that its cut edge did not bleed so profusely as usual. However, since the spleen had not been removed and the short gastric vessels seemed to be intact, it was thought that sufficient blood supply remained to maintain gastric viability. A retrocolic isoperistaltic Polya-Hofmeister type of reconstruction was done. A transnasal double lumen tube was inserted into the efferent loop of the jejunum. The patient did fairly well for several days, and then began running a fever which responded to penicillin, streptomycin and oxytetracycline (Terramycin). On the eighth postoperative day dullness to percussion over the left lower chest was noted, and an x-ray showed cloudiness of the left lower lung field. However, since the patient's temperature had returned to normal, he was kept under observation for 2 additional days. A repeat x-ray showed bilateral cloudiness of the lower lung fields with an air bubble under the right diaphragm. A preoperative diagnosis of bilateral subphrenic abscesses was made. On September 18, bilateral subcostal incisions revealed a large amount of purulent, foul-smelling pus in the subphrenic space on the left and in the subhepatic space on the right. There was a large amount of air but no pus over the dome of the liver on the right. Bilateral drainage was instituted. A few days following this, large amounts of fluid drained away, indicative of a gastric fistula; methylene blue taken orally appeared on the dressings. The patient was again taken to surgery on November 25. It became evident after opening the abdomen that a thoracoabdominal incision would be necessary in order to approach the fistula into the stomach (Fig. 3). It was thought advisable to try to improve the patient's physical condition before this was done. The afferent limb of the jejunum was
Figure 3. Location of the gastric fistula in case being reported.
PERFORATION OF AN ISCHEMIC PROXIMAL GASTRIC REMNANT
305
Figure 4. Method of dealing with the gastric fistula before its final closure.
Witzel jejunostomy
severed just proximal to the stomach and the distal end inverted. The duodenum and beginning jejunum were then taken out from under the superior mesenteric vessels and anastomosed end-to-side to the jejunum about 2 feet beyond its anastomosis to the stomach (Fig. 4). This was done in order to sidetrack the pancreatic secretion, which was digesting the abdominal wall. Beyond this anastomosis, a No. 18 French catheter was inserted into the jejunum by the Witzel technique and brought out through a stab wound. The patient was fed through the jejunostomy tube and his condition improved sufficiently to justify an operation to close the gastric fistula, which, meanwhile, had not closed spontaneously. On November 27, the stomach was mobilized through a thoracoabdominal approach, and the fistulous opening identified. So far as could be told, it had resulted from failure of union between the stomach and the jejunum. The fistulous edges were inverted by a row of interrupted chromic catgut sutures and an outer row of interrupted silk. The patient stood the operation well. He was able to eat without evidence of recurrence of gastric leakage. Eighteen days later he returned home; he died suddenly 2 days later, apparently of a heart attack. Autopsy was not permitted.
DISCUSSION Ischemia of the remaining stomach following radical gastrectomy must indeed be a rare occurrence. Many cases of radical resection of the stomach have been reported in which only the esophageal vessels and the left phrenic artery remained to supply the gastric remnant and there has been no ensuing difficulty.
306
]. E. STRODE
Wangensteen 10 has reported leaving a pouch of 5 per cent of the stomach, devoid of all blood supply except for branches of the esophageal arteries, in doing segmental gastric resection, without impairment of blood supply to the gastric remnant. Hinton and Localio 4 have had similar results under like circumstances. No doubt some complications due to compromise of the vascular supply of the gastric remnant have gone unrecognized. In our own case at the time of the original operation we were concerned about the blood supply to the remaining stomach being adequate, both because of its color and because of scanty bleeding along its cut edges. However, not having had any trouble previously following high gastric resection, even when the spleen was removed, it was concluded that we were probably unduly apprehensive. Up to that time no one had called attention to the possibility of ischemia of the remaining stomach after gastric resection. Most of the cases reported have followed high gastric resection when the left gastric artery was ligated at its origin and the spleen was removed. In a case reported by Jackson,5 as in the one here reported, the spleen was not removed. Most of the cases reported did not mention cyanosis of the stomach or apparent diminution in bleeding along the cut edge of the stomach. When such findings are apparent, one should probably proceed with total gastrectomy despite the hope that sufficient circulation remains. It will take considerable fortitude on the part of the surgeon to decide to do a total gastrectomy when there is uncertainty that sufficient circulation remains to permit adequate healing of the anastomosis or to prevent the stomach's perforating, especially since, over the years, so little attention has been called to such a possibility. However, only two recoveries have been reported following this complication and both patients were eventually subjected to total gastrectomy. No doubt the varying degrees of impairment of circulation determine the extent of gastric necrosis. Most of the cases reported resulted in extensive destruction of the gastric wall. In our patient, there apparently was enough blood supply to prevent such widespread destruction, but not enough to permit union between the gastric wall and the jejunum. In high gastric resection it would seem advisable to ligate the left gastric artery beyond its division, since this would permit the intact ascending branch to contribute to the circulation of the upper part of the stomach and lower esophagus. At times the left phrenic artery has been found to arise from the left gastric artery. When this occurs and the left gastric artery is ligated at its origin and the spleen is removed, it leaves the remaining stomach precariously vascularized by the esophageal arteries; ischemia may well result. When a high resection is done, especially in case the ulcer has penetrated into the pancreas, adequate drainage of the area should be instituted. A left subphrenic infection is liable to occur under these circumstances, and when ischemia of the gastric remnant seems possible, detection of perforation might be recognized earlier. In the case being reported we cannot account for the lack of blood supply to the remaining stomach because no autopsy was obtained.
PERFORATION OF AN ISCHEMIC PROXIMAL GASTRIC REMNANT
307
Perhaps the splenic artery became thrombosed due to penetration of the ulcer into the pancreas adjacent to this vessel. The patient's age, 57, places him in the age group in whom atheromatous changes may well be a contributing factor.
CONCLUSIONS Though ischemia of a gastric remnant is rare, the surgeon doing a high gastric resection should always bear the possibility of its occurrence in mind. Unless there are adequate indications for removal of the spleen, it should be left intact. When possible, the left gastric artery should be ligated distal to the branch ascending to the gastroesophageal area. The surgeon should remember that the left hepatic artery and the left phrenic artery at times arise from the left gastric artery and should be cognizant of the dangers of ligating the left gastric artery at its origin under these circumstances. After high gastric resections the operative area should be drained, particularly if the ulcer has penetrated into the pancreas. It is reassuring to know that the stomach is so well vascularized that, regardless of how radically it is removed, the part remaining rarely suffers from ischemia. The case being reported is the only instance in approximately 1500 gastric resections in which, to our knowledge, postoperative complications developed due to ischemia of the remaining stomach. In all probability others have occurred but were not recognized.
REFERENCES 1. Brown, J. R., and Derr, J. W.: Arterial blood supply of the human stomach. A.M.A. Arch.
Surg., 65:37, 1952. 2. Friesen, S. R.: The significance of anomalous origin of the left hepatic artery from the left gastric in operations upon the stomach and esophagus. Amer. Surg., 23:1103-1108, 1957. 3. Harkins, H. N.: Discussion of Jackson.' Ann. Surg., 150:1074, 1959. 4. Hinton, J. W., and Locatio, S. A.: Surgical management of gastric ulcer high on the lesser curvature. Arch. Surg., 60:267, 1950. 5. Jackson, P. P.: Ischemic necrosis of the proximal gastric remnant following subtotal gastrectomy. Ann. Surg., 150:1071-1073, 1959. 6. Rutter, A. G.: Ischemic necrosis of the stomach following subtotal gastrectomy. Lancet, 2:1021-1022, 1953. 7. Somervell, T. H.: Physiological gastrectomy. Brit. J. Surg., 33:146, 1945. 8. Spencer, D. C.: Ischemic necrosis of remaining stomach following subtotal gastrectomy. A.M.A. Arch. Surg., 73:844, 1956. 9. Thompson, N. W.: Ischemic necrosis of proximal gastric remnant following subtotal gastrectomy. Surgery, 54:434-440, 1963. 10. Wangensteen, 0. H.: Segmental gastric resection for peptic ulcer. Method permitting restoration of anatomic continuity. J.A.M.A., 149:18, 1952.
It is the belief of most surgeons that the blood supply to the stomach is so ample that the danger of ischemia need not be considered when doing a gastric resection. Undoubtedly this is the case unless the blood supply is anomalous or the remaining vessels have become occluded by atherosclerotic changes. Brown and Derr 1 made a study of the blood supply of the human stomach, using the injection technique in cadavers, and found complete filling of all the intramural vessels by injection of any one of the four major arteries with all other extramural vessels ligated. Fairly complete filling occurred after injection of one short gastric artery with all others ligated. Somervell 7 reported over 400 patients with duodenal ulcers in whom four fifths of the branches of the major arteries to the stomach were ligated without ensuing necrosis. Rutter 6 in 1953 reported what was apparently the first case of ischemia of the remaining stomach after gastric resection, for he was unable to find any other references to this condition after carefully scanning the literature of the previous 20 years. Over the ensuing years an occasional case has been reported. Thompson9 in 1963 described four cases encountered at the University of Michigan Medical Center and said that up to that time only 12 other cases had been recorded in the world literature. No doubt many cases have occurred that have not found their way into the medical literature. Spencer,8 in personal communications with three surgeons who had had extensive experience with gastric surgery, found that each had seen two cases, and in five of the six the left gastric artery had been ligated and the spleen had been removed. Harkins 3 stated that in a series of 500 subtotal gastrectomies he had seen two instances of the "blue stomach syndrome" after division of the left gastric artery and all of the vasa brevia. One patient had no difficulty; *Department of General Surgery, Straub Clinic, Honolulu, Hawaii
Surgical Clinics of North America- Vol. 50, No. 2, April, 1970
301
J, E.
302
STRODE
the other, who was 81 years old, developed a fatal anastomotic leak, but no necrosis was noted at autopsy. To explain more clearly the problem of ischemia of the remaining portion of the stomach after subtotal gastric resection, a brief review of the arterial supply to the proximal area of this organ seems advisable. Figure 1 demonstrates the arterial supply as normally encountered in the stomach, and Figure 2 shows the blood supply to the proximal stomach after the usual high gastric resection without removal of the spleen. The major arterial supply to the stomach arises from the celiac axis. The lesser curvature of the stomach is supplied by the right and left gastric arteries and the gastroduodenal and splenic arteries. The short gastric arteries, or the vasa brevia, arise from the splenic artery just before it divides into its terminal branches. The left phrenic artery arises from the aorta, or at times from the common trunk of the celiac artery, and supplies blood to the lower esophagus and adjacent stomach. Esophageal arteries arise directly from the aorta and the lower ones anastomose with the ascending esophageal branches of the phrenic and gastric arteries below. In the usual procedure of performing a high gastric resection the left gastric artery is ligated at its origin, and if the spleen is left in place there should be ample blood supply to the remaining stomach through the short gastric branches of the splenic, the esophageal and the inferior
L. phrenic a.-
R.gastric a.
''
'
''
'
gastroep1olo1c
1.
Figure 1. Normal blood supply to the stomach and lower esophagus.
PERFORATION OF AN ISCHEMIC PROXIMAL GASTRIC REMNANT
303
L.gastric
Figure 2. Blood supply to the remaining stomach after the usual gastric resection in which the spleen is not removed.
phrenic arteries (Fig. 2). If the spleen is removed, the blood supply is then dependent upon the esophageal and phrenic arteries. Many high gastric resections have been done, with these vessels alone remaining, without compromise to the circulation of the gastric remnant. One would be more certain of an adequate blood supply, however, if the left gastric arteries were divided beyond the ascending branch that extends to the gastroesophageal area. The importance of these short gastric vessels is emphasized in Thompson's report 9 of a 90 per cent gastric resection for a benign high gastric ulcer in which the spleen was not removed, thus preserving the short gastric arteries. Hemorrhage a week later necessitated ligation of the splenic artery and removal of the spleen. The gastric pouch and anastomosis were intact at that time. The patient died 1 week later, and autopsy showed ischemic necrosis of the stomach remnant. At times it has been noted that the blood supply to the left lobe of the liver arises from the left gastric artery. Friesen 2 has noted this occurrence in several patients coming to surgery, and in one instance in which this was not recognized and the left gastric artery was ligated proximal to the origin of the left hepatic artery, death occurred and was attributed to necrosis of the left lobe of the liver. CASE REPORT. A white man, aged 57, was operated upon on September 10 for a large penetrating ulcer of the upper lesser curvature of the stomach. At operation the lesion appeared to be malignant, but was later found to be benign. It had penetrated into the distal portion of the pancreas. A fairly radical resection was done, and the lymph nodes were cleaned out along the lesser curvature of the stomach as high as the esophagus. Most of the omentum and about 75 per cent of the stomach were removed, but the spleen was not. The left gastric artery was ligated and severed at its origin at the celiac axis. It was noted at the time of the
304
J, E.
STRODE
operation that the color of the remaining stomach was bluer than usual and that its cut edge did not bleed so profusely as usual. However, since the spleen had not been removed and the short gastric vessels seemed to be intact, it was thought that sufficient blood supply remained to maintain gastric viability. A retrocolic isoperistaltic Polya-Hofmeister type of reconstruction was done. A transnasal double lumen tube was inserted into the efferent loop of the jejunum. The patient did fairly well for several days, and then began running a fever which responded to penicillin, streptomycin and oxytetracycline (Terramycin). On the eighth postoperative day dullness to percussion over the left lower chest was noted, and an x-ray showed cloudiness of the left lower lung field. However, since the patient's temperature had returned to normal, he was kept under observation for 2 additional days. A repeat x-ray showed bilateral cloudiness of the lower lung fields with an air bubble under the right diaphragm. A preoperative diagnosis of bilateral subphrenic abscesses was made. On September 18, bilateral subcostal incisions revealed a large amount of purulent, foul-smelling pus in the subphrenic space on the left and in the subhepatic space on the right. There was a large amount of air but no pus over the dome of the liver on the right. Bilateral drainage was instituted. A few days following this, large amounts of fluid drained away, indicative of a gastric fistula; methylene blue taken orally appeared on the dressings. The patient was again taken to surgery on November 25. It became evident after opening the abdomen that a thoracoabdominal incision would be necessary in order to approach the fistula into the stomach (Fig. 3). It was thought advisable to try to improve the patient's physical condition before this was done. The afferent limb of the jejunum was
Figure 3. Location of the gastric fistula in case being reported.
PERFORATION OF AN ISCHEMIC PROXIMAL GASTRIC REMNANT
305
Figure 4. Method of dealing with the gastric fistula before its final closure.
Witzel jejunostomy
severed just proximal to the stomach and the distal end inverted. The duodenum and beginning jejunum were then taken out from under the superior mesenteric vessels and anastomosed end-to-side to the jejunum about 2 feet beyond its anastomosis to the stomach (Fig. 4). This was done in order to sidetrack the pancreatic secretion, which was digesting the abdominal wall. Beyond this anastomosis, a No. 18 French catheter was inserted into the jejunum by the Witzel technique and brought out through a stab wound. The patient was fed through the jejunostomy tube and his condition improved sufficiently to justify an operation to close the gastric fistula, which, meanwhile, had not closed spontaneously. On November 27, the stomach was mobilized through a thoracoabdominal approach, and the fistulous opening identified. So far as could be told, it had resulted from failure of union between the stomach and the jejunum. The fistulous edges were inverted by a row of interrupted chromic catgut sutures and an outer row of interrupted silk. The patient stood the operation well. He was able to eat without evidence of recurrence of gastric leakage. Eighteen days later he returned home; he died suddenly 2 days later, apparently of a heart attack. Autopsy was not permitted.
DISCUSSION Ischemia of the remaining stomach following radical gastrectomy must indeed be a rare occurrence. Many cases of radical resection of the stomach have been reported in which only the esophageal vessels and the left phrenic artery remained to supply the gastric remnant and there has been no ensuing difficulty.
306
]. E. STRODE
Wangensteen 10 has reported leaving a pouch of 5 per cent of the stomach, devoid of all blood supply except for branches of the esophageal arteries, in doing segmental gastric resection, without impairment of blood supply to the gastric remnant. Hinton and Localio 4 have had similar results under like circumstances. No doubt some complications due to compromise of the vascular supply of the gastric remnant have gone unrecognized. In our own case at the time of the original operation we were concerned about the blood supply to the remaining stomach being adequate, both because of its color and because of scanty bleeding along its cut edges. However, not having had any trouble previously following high gastric resection, even when the spleen was removed, it was concluded that we were probably unduly apprehensive. Up to that time no one had called attention to the possibility of ischemia of the remaining stomach after gastric resection. Most of the cases reported have followed high gastric resection when the left gastric artery was ligated at its origin and the spleen was removed. In a case reported by Jackson,5 as in the one here reported, the spleen was not removed. Most of the cases reported did not mention cyanosis of the stomach or apparent diminution in bleeding along the cut edge of the stomach. When such findings are apparent, one should probably proceed with total gastrectomy despite the hope that sufficient circulation remains. It will take considerable fortitude on the part of the surgeon to decide to do a total gastrectomy when there is uncertainty that sufficient circulation remains to permit adequate healing of the anastomosis or to prevent the stomach's perforating, especially since, over the years, so little attention has been called to such a possibility. However, only two recoveries have been reported following this complication and both patients were eventually subjected to total gastrectomy. No doubt the varying degrees of impairment of circulation determine the extent of gastric necrosis. Most of the cases reported resulted in extensive destruction of the gastric wall. In our patient, there apparently was enough blood supply to prevent such widespread destruction, but not enough to permit union between the gastric wall and the jejunum. In high gastric resection it would seem advisable to ligate the left gastric artery beyond its division, since this would permit the intact ascending branch to contribute to the circulation of the upper part of the stomach and lower esophagus. At times the left phrenic artery has been found to arise from the left gastric artery. When this occurs and the left gastric artery is ligated at its origin and the spleen is removed, it leaves the remaining stomach precariously vascularized by the esophageal arteries; ischemia may well result. When a high resection is done, especially in case the ulcer has penetrated into the pancreas, adequate drainage of the area should be instituted. A left subphrenic infection is liable to occur under these circumstances, and when ischemia of the gastric remnant seems possible, detection of perforation might be recognized earlier. In the case being reported we cannot account for the lack of blood supply to the remaining stomach because no autopsy was obtained.
PERFORATION OF AN ISCHEMIC PROXIMAL GASTRIC REMNANT
307
Perhaps the splenic artery became thrombosed due to penetration of the ulcer into the pancreas adjacent to this vessel. The patient's age, 57, places him in the age group in whom atheromatous changes may well be a contributing factor.
CONCLUSIONS Though ischemia of a gastric remnant is rare, the surgeon doing a high gastric resection should always bear the possibility of its occurrence in mind. Unless there are adequate indications for removal of the spleen, it should be left intact. When possible, the left gastric artery should be ligated distal to the branch ascending to the gastroesophageal area. The surgeon should remember that the left hepatic artery and the left phrenic artery at times arise from the left gastric artery and should be cognizant of the dangers of ligating the left gastric artery at its origin under these circumstances. After high gastric resections the operative area should be drained, particularly if the ulcer has penetrated into the pancreas. It is reassuring to know that the stomach is so well vascularized that, regardless of how radically it is removed, the part remaining rarely suffers from ischemia. The case being reported is the only instance in approximately 1500 gastric resections in which, to our knowledge, postoperative complications developed due to ischemia of the remaining stomach. In all probability others have occurred but were not recognized.
REFERENCES 1. Brown, J. R., and Derr, J. W.: Arterial blood supply of the human stomach. A.M.A. Arch.
Surg., 65:37, 1952. 2. Friesen, S. R.: The significance of anomalous origin of the left hepatic artery from the left gastric in operations upon the stomach and esophagus. Amer. Surg., 23:1103-1108, 1957. 3. Harkins, H. N.: Discussion of Jackson.' Ann. Surg., 150:1074, 1959. 4. Hinton, J. W., and Locatio, S. A.: Surgical management of gastric ulcer high on the lesser curvature. Arch. Surg., 60:267, 1950. 5. Jackson, P. P.: Ischemic necrosis of the proximal gastric remnant following subtotal gastrectomy. Ann. Surg., 150:1071-1073, 1959. 6. Rutter, A. G.: Ischemic necrosis of the stomach following subtotal gastrectomy. Lancet, 2:1021-1022, 1953. 7. Somervell, T. H.: Physiological gastrectomy. Brit. J. Surg., 33:146, 1945. 8. Spencer, D. C.: Ischemic necrosis of remaining stomach following subtotal gastrectomy. A.M.A. Arch. Surg., 73:844, 1956. 9. Thompson, N. W.: Ischemic necrosis of proximal gastric remnant following subtotal gastrectomy. Surgery, 54:434-440, 1963. 10. Wangensteen, 0. H.: Segmental gastric resection for peptic ulcer. Method permitting restoration of anatomic continuity. J.A.M.A., 149:18, 1952.