- Email: [email protected]
Resection of stomach for carcinoma: Three years after operation
N e w Series VoL. I, N o . 5
Section of Surgery
scaphoid type with scar in right Iower quadrant. No tenderness or masses could be detected. At the apex of the right Iung, there was some dullness, and a few suberepitant r~Ies couId be heard. Physical examination otherwise negative. Urine, negative. BIood count: w.b.c., i2,6oo; polynuclears, 9 ° per cent; Iymphocytes 9 per cent. X-ray examination showed pronounced fiIIing defect in the duodenum with some retention o f the meaI after 6 hours. Wassermann reaction negative. Operation. Findings: CicatriciaI infiltration diffuse through pylorus and first portion of duodenum. GalI bIadder thickened and bound down so intimateIy to duodenum as to be aImost indistinguishable. Procedure: GaIIbIadder dissected out, cystic duct identified and galIbIadder removed from beIow upwards. MobiIization of the pyIorus and duodenum started from the gastric side, Iesser omentum cut and tied, pyloric and Ieft gastric arteries cut between damps and Iigated. Greater curvature then isoIated in a simiIar manner and Payr crushing cIamp applied at the pyloric region of the stomach wail proximaI to area of cicatriciaI infiItration. Stomach then amputated between clamps and turned distally in an effort to mobilize duodenum which was accomplished through first portion. During dissection at this point, the friabIe tissues of the duodenum tore compIetely through, leaving the ragged, infiltrated stump of duodenum wide open. The mucous membrane of the duodenum was then dosed by continuous chromic catgut suture. Attempts to close serosa and unite it for efficient cIosure over the stump faiIing because of the infiltration of the wails, the closure was compIeted by displacing the posterior peritoneum covering the pancreas IateralIy in such a way as to permit suturing of the Iatter over the incompIeteIy closed duodenaI stump after the manner of an inverted cup. The edges of this cup were puIIed weII down over the duodenum andsutured closeIy about it in the comparativeIy healthy tissues of the second portion. Operation was compIeted by anastomosing the jejunum to the cut end of the stomach after themanner of PoIya. The postoperative course was uneventfuI and the patient was discharged from the hospitaI within three weeks. He has been absoIutely free from digestive symptoms and has gained very rapidly in health, weight and strength.
A~.~i~. J. . . . . I of S u r g e r y
289
Comment. This case is presented because of interesting features reIating to the method of closure of the duodenum. Serosa cIosure could not be effected and the substitution of posterior peritoneum without consequent Ieakage or fistuIa suggests the method as a routine plan in cIosure of duodenaI stumps in this operation where Ieakage and fistuIae often determine a fatal outcome. RESECTION OF STOMACH FOR CARCINOMA: T H R E E YEARS A F T E R OPERATION JOHN
H.
MORRIS.
M.D.
A female, 48 years of age, was admitted to the Fourth SurgicaI Division, BelIevue HospitaI, with marked carcinomatous cachexia. Digestive symptoms had begun but three months before admission with gaseous distention after food. One month Iater, she noted epigastric pain two hours after meals accompanied by generaI abdominaI distention, heartburn and "Iumps" or "knots" in the upper abdomen. Appetite was fairIy good but the diet was limited by desire to eliminate the distress which foIIowed eating. RecentIy she had frequent spelIs of vomiting, the vomitus being dark, of foul odor and containing much undigested food. She reported a Ioss of about ao pounds in weight during the Iast 6 months. She had never experienced any heart or lung troubIe but had had influenza in I9ea. She had aIso complained of a right inguinal hernia for many years. She had been pregnant ten times, going through normaI deIiveries and had had 5 or 6 miscarriages. There was no history of maIignancy in the family. The patient was extremely emaciated, palIid and weak. The skin was very dry and loose. The abdomen was retracted and the muscIes were Iax and wasted. In the upper right quadrant, there was a hard, freely movabIe, painIess mass apparentIy about the size of an orange. The right kidney was moderateIy prosed and Iiver edge was readiIy palpabIe. There was a Iarge Ieft iaguinaI hernia. Examination otherwise negative. The urine showed a trace of aIbumin. BIood count: r.b.c., 2,400,ooo; hemogIobin, 35 per cent; w.b.c., 7,40o; polynuclears, 59 per cent; Iymphoeytes, 37 per cent. X-ray examination: Complete pyIoric obstruction with tremendous diIatation of the stomach which fiIIed almost the entire abdomen; diag-
290
[American J . . . . al of Surgery
Section of Surgery
'NOvEMt'~ER, I92(3
nosis: calloused ulcer with probable malignant •tympanitic; and generalized muscular rigidity degeneration. precIuded the possibility of detecting intraOperation. Preliminary transfusion of 7oo abdominaI masses. The rigidity was particuc.c. of bIood. Findings: Large annular mass IarIy marked over the entire right rectus muscIe 'occupying the pylorus. GreatIy dilated stom- and here the acute tenderness appeared to be ach. Gastric mass freely movabIe. Subpyloric concentrated. UrinaIysis, negative. Blood count glands greatly enlarged. w.b.c., 16,6oo; polynuclears, 83 per cent; Procedure: Lesser omentum freed from Iymphocytes, 17 per cent. Preoperative diagstomach between ligatures. Ligature of pyIoric nosis: ruptured appendix with general periand left gastric arteries. Greater omentum tonitis. similarIy freed from greater curvature and Operation. Right rectus incision. Upon arteries Iigated. Duodenum then amputated opening the abdomen, a large, firm brownishbetween Payr clamps, stump inverted and red mass appeared to fiII the right side of the buried within serosaI overIap. Payr clamp then abdomen. This mass proved to be engorged appIied to stomach tangentiaI to Iesser curva- and congested omentum which was twisted ture and distaI portion removed between upon itself seven distinct turns. This torsion clamps. Loop of jejunum then brought up had taken pIace in cIose proximity to the anterior to transverse coIon and anastomosis attachment of the omentum to the transmade between it and cut end of stomach after verse coIon and at this point the entire omenmethod of Polya-Balfour. tum was gathered into a narrow pedicIe, distal The pathologicaI report was ulcerating to which was the Iarge, red, beefy mass repreadenocarcinoma of the stomach. sented by the compIeteIy invoIved omentum. The postoperative course was very pIacid A compIete removaI of the omentum was and the patient was discharged from hospitaI done. The appendix was found definitely 19 days after operation. During the ensuing involved in a subacute inflammatory process, two years she has gained from her admission and it was accordingIy removed. Pathological weight of 9o pounds to 14o pounds and has report: subsiding acute appendicitis; hemorhad no digestive distress of any sort. rhagic infarction of twisted omentum. The Comment. This case is shown as a three- patient enjoyed an uncomplicated redovery. year result in a case of weII advanced carciComment. The features to be emphasized noma of the stomach presenting originalIy a in this case are: the torsion of the omentum hemogIobin percentage of 33, a tremendous in association with a subsiding acute appengastric dilatation and an excessive degree of dicitis which was evidently the inciting cause of the omentaI lesion; the obesity of the subject, emaciation. which was evidently a contributory factor due to excessive fat deposit in the omentum; and TORSION OF T H E OMENTUM finaIIy the invoIvement of the entire omentum JOHN H. MORRIS, M.D. in this case, which is not usually observed. This patient was admitted to Post-Graduate Hospital as an acute emergency on January TORSION OF THE GREAT OMENTUM: RESECTION 28, 1926. Two days previously, he had been seized with severe, generalized abdominaI JOHN H° GARLOCK, M.D. pain associated at the onset with nausea and vomiting. During the ensuing twelve hours An Italian housewife, aged 43 years, was the pain had Iocalized itself in the right lower ,admitted to the Second Surgical Division of quadrant and there remained continuous up the New York Hospital, JuIy 15, 1925 and to the time of admission. Bowels constipated, was discharged JuIy 3o, 1925. She compIained no diarrhea and no urinary disturbances. o f pain in the right lower quadrant of one The man's previous health had always been week's duration. One week before she was good and he had never before experienced admitted, she was seized with sudden pain in simiIar attacks nor had had any type of diges- the Iower abdomen. This graduaIIy localized in the right Iower quadrant and remained in this tive disturbance. He was an obese, robust, young, white maIe. situation. It was severe and at times cramp-Iike. His temperature (rectal) was lO2° and his There was no nausea or vomiting. She feIt feverpuIse rate IiO. His abdomen was distended ish for a few days and aIso compIained of generaI
Section of Surgery
scaphoid type with scar in right Iower quadrant. No tenderness or masses could be detected. At the apex of the right Iung, there was some dullness, and a few suberepitant r~Ies couId be heard. Physical examination otherwise negative. Urine, negative. BIood count: w.b.c., i2,6oo; polynuclears, 9 ° per cent; Iymphocytes 9 per cent. X-ray examination showed pronounced fiIIing defect in the duodenum with some retention o f the meaI after 6 hours. Wassermann reaction negative. Operation. Findings: CicatriciaI infiltration diffuse through pylorus and first portion of duodenum. GalI bIadder thickened and bound down so intimateIy to duodenum as to be aImost indistinguishable. Procedure: GaIIbIadder dissected out, cystic duct identified and galIbIadder removed from beIow upwards. MobiIization of the pyIorus and duodenum started from the gastric side, Iesser omentum cut and tied, pyloric and Ieft gastric arteries cut between damps and Iigated. Greater curvature then isoIated in a simiIar manner and Payr crushing cIamp applied at the pyloric region of the stomach wail proximaI to area of cicatriciaI infiItration. Stomach then amputated between clamps and turned distally in an effort to mobilize duodenum which was accomplished through first portion. During dissection at this point, the friabIe tissues of the duodenum tore compIetely through, leaving the ragged, infiltrated stump of duodenum wide open. The mucous membrane of the duodenum was then dosed by continuous chromic catgut suture. Attempts to close serosa and unite it for efficient cIosure over the stump faiIing because of the infiltration of the wails, the closure was compIeted by displacing the posterior peritoneum covering the pancreas IateralIy in such a way as to permit suturing of the Iatter over the incompIeteIy closed duodenaI stump after the manner of an inverted cup. The edges of this cup were puIIed weII down over the duodenum andsutured closeIy about it in the comparativeIy healthy tissues of the second portion. Operation was compIeted by anastomosing the jejunum to the cut end of the stomach after themanner of PoIya. The postoperative course was uneventfuI and the patient was discharged from the hospitaI within three weeks. He has been absoIutely free from digestive symptoms and has gained very rapidly in health, weight and strength.
A~.~i~. J. . . . . I of S u r g e r y
289
Comment. This case is presented because of interesting features reIating to the method of closure of the duodenum. Serosa cIosure could not be effected and the substitution of posterior peritoneum without consequent Ieakage or fistuIa suggests the method as a routine plan in cIosure of duodenaI stumps in this operation where Ieakage and fistuIae often determine a fatal outcome. RESECTION OF STOMACH FOR CARCINOMA: T H R E E YEARS A F T E R OPERATION JOHN
H.
MORRIS.
M.D.
A female, 48 years of age, was admitted to the Fourth SurgicaI Division, BelIevue HospitaI, with marked carcinomatous cachexia. Digestive symptoms had begun but three months before admission with gaseous distention after food. One month Iater, she noted epigastric pain two hours after meals accompanied by generaI abdominaI distention, heartburn and "Iumps" or "knots" in the upper abdomen. Appetite was fairIy good but the diet was limited by desire to eliminate the distress which foIIowed eating. RecentIy she had frequent spelIs of vomiting, the vomitus being dark, of foul odor and containing much undigested food. She reported a Ioss of about ao pounds in weight during the Iast 6 months. She had never experienced any heart or lung troubIe but had had influenza in I9ea. She had aIso complained of a right inguinal hernia for many years. She had been pregnant ten times, going through normaI deIiveries and had had 5 or 6 miscarriages. There was no history of maIignancy in the family. The patient was extremely emaciated, palIid and weak. The skin was very dry and loose. The abdomen was retracted and the muscIes were Iax and wasted. In the upper right quadrant, there was a hard, freely movabIe, painIess mass apparentIy about the size of an orange. The right kidney was moderateIy prosed and Iiver edge was readiIy palpabIe. There was a Iarge Ieft iaguinaI hernia. Examination otherwise negative. The urine showed a trace of aIbumin. BIood count: r.b.c., 2,400,ooo; hemogIobin, 35 per cent; w.b.c., 7,40o; polynuclears, 59 per cent; Iymphoeytes, 37 per cent. X-ray examination: Complete pyIoric obstruction with tremendous diIatation of the stomach which fiIIed almost the entire abdomen; diag-
290
[American J . . . . al of Surgery
Section of Surgery
'NOvEMt'~ER, I92(3
nosis: calloused ulcer with probable malignant •tympanitic; and generalized muscular rigidity degeneration. precIuded the possibility of detecting intraOperation. Preliminary transfusion of 7oo abdominaI masses. The rigidity was particuc.c. of bIood. Findings: Large annular mass IarIy marked over the entire right rectus muscIe 'occupying the pylorus. GreatIy dilated stom- and here the acute tenderness appeared to be ach. Gastric mass freely movabIe. Subpyloric concentrated. UrinaIysis, negative. Blood count glands greatly enlarged. w.b.c., 16,6oo; polynuclears, 83 per cent; Procedure: Lesser omentum freed from Iymphocytes, 17 per cent. Preoperative diagstomach between ligatures. Ligature of pyIoric nosis: ruptured appendix with general periand left gastric arteries. Greater omentum tonitis. similarIy freed from greater curvature and Operation. Right rectus incision. Upon arteries Iigated. Duodenum then amputated opening the abdomen, a large, firm brownishbetween Payr clamps, stump inverted and red mass appeared to fiII the right side of the buried within serosaI overIap. Payr clamp then abdomen. This mass proved to be engorged appIied to stomach tangentiaI to Iesser curva- and congested omentum which was twisted ture and distaI portion removed between upon itself seven distinct turns. This torsion clamps. Loop of jejunum then brought up had taken pIace in cIose proximity to the anterior to transverse coIon and anastomosis attachment of the omentum to the transmade between it and cut end of stomach after verse coIon and at this point the entire omenmethod of Polya-Balfour. tum was gathered into a narrow pedicIe, distal The pathologicaI report was ulcerating to which was the Iarge, red, beefy mass repreadenocarcinoma of the stomach. sented by the compIeteIy invoIved omentum. The postoperative course was very pIacid A compIete removaI of the omentum was and the patient was discharged from hospitaI done. The appendix was found definitely 19 days after operation. During the ensuing involved in a subacute inflammatory process, two years she has gained from her admission and it was accordingIy removed. Pathological weight of 9o pounds to 14o pounds and has report: subsiding acute appendicitis; hemorhad no digestive distress of any sort. rhagic infarction of twisted omentum. The Comment. This case is shown as a three- patient enjoyed an uncomplicated redovery. year result in a case of weII advanced carciComment. The features to be emphasized noma of the stomach presenting originalIy a in this case are: the torsion of the omentum hemogIobin percentage of 33, a tremendous in association with a subsiding acute appengastric dilatation and an excessive degree of dicitis which was evidently the inciting cause of the omentaI lesion; the obesity of the subject, emaciation. which was evidently a contributory factor due to excessive fat deposit in the omentum; and TORSION OF T H E OMENTUM finaIIy the invoIvement of the entire omentum JOHN H. MORRIS, M.D. in this case, which is not usually observed. This patient was admitted to Post-Graduate Hospital as an acute emergency on January TORSION OF THE GREAT OMENTUM: RESECTION 28, 1926. Two days previously, he had been seized with severe, generalized abdominaI JOHN H° GARLOCK, M.D. pain associated at the onset with nausea and vomiting. During the ensuing twelve hours An Italian housewife, aged 43 years, was the pain had Iocalized itself in the right lower ,admitted to the Second Surgical Division of quadrant and there remained continuous up the New York Hospital, JuIy 15, 1925 and to the time of admission. Bowels constipated, was discharged JuIy 3o, 1925. She compIained no diarrhea and no urinary disturbances. o f pain in the right lower quadrant of one The man's previous health had always been week's duration. One week before she was good and he had never before experienced admitted, she was seized with sudden pain in simiIar attacks nor had had any type of diges- the Iower abdomen. This graduaIIy localized in the right Iower quadrant and remained in this tive disturbance. He was an obese, robust, young, white maIe. situation. It was severe and at times cramp-Iike. His temperature (rectal) was lO2° and his There was no nausea or vomiting. She feIt feverpuIse rate IiO. His abdomen was distended ish for a few days and aIso compIained of generaI