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RUPTURE OF DUODENAL STUMP AFTER GASTRECTOMY
721 describe the first group. Adenosis in this
sense is neither disease nor a menace. On the other hand, once a neoplasia is established, its destination may be earmarked, biologically, from the
We stated that a point incidental to the Roux-en-Y type of anastomosis was that the duodenal contents pass uninterrupted into the jejunum, thus diminishing the risk of a blown duodenal stumpy My experience with the Roux-en-Y anastomosis has been that, while a small number of minor duodenal leaks have been encountered (about the seventh day with little inconvenience to the patient), there have been This no cases of catastrophic burst duodenal stump. an may prove important advantage. My experience supports the claim that a distended afferent loop is an important factor in rupture of a duodenal stump.
syndrome.
a
one way or the other, near be occasion impossible. A variety of physiomay and may be found in sections patterns pathological logical from different areas of the same breast. These are often interpreted as stepping-stones to disaster, but presumably, could be tissue reactions to a varying chemical status. F. D. SANER.
start; yet histological confirmation, on
Victoria Hospital, Swindon, Wiltshire.
PNEUMOCONIOSIS 1
SIR,—Dr. Triger has commented
on
the lack of
com-
PERFORATED DUODENAL ULCER AND SLEEPING POSITION
pneumoconiosis diagnoses during life with parisons post-mortem findings, and Dr. Fletcher 2 has subsequently drawn attention to the observer error in pathological of
SIR,—Few will dispute that hyperchlorhydria is an important factor in duodenal ulceration. The following investigation was suggested by the possibility that gastric and duodenal night secretions, collecting at the most dependent portion of that part of the gut, might there cause ulceration. The most dependent portion will, of course, vary with the patient’s position ; but changes of position are very much less at night, and so it seemed reasonable to expect some relationship between sleeping posture and the site of ulceration.
assessment. This problem of comparing diagnoses post-mortem findings in silicosis has studied in Germany.
intra vitam with been repeatedly
Worth and Nerreter 3 have analysed the data for 327 cases of silicosis confirmed by necropsy. The degree of silicosis was based on the older classification into stages I, II, and III. In 83% of the cases there was agreement between clinical and post-mortem findings for the degree of silicosis found. Taking the necropsy findings as correct, the clinical results overestimated the disease in 8% of the cases and underestimated it in another 8%. The overestimates occurred chiefly in stages O-II and the underestimates in stage III.
One obvious objection is that the lie of the stomach is very variable ; for this reason gastric ulceration was ignored throughout the investigation. The position of the duodenum is also variable, but the differences are comparatively slight. The anterior surface of the first part of the duodenum nearly always passes transversely from left to right with a slight tilt superiorly and posteriorly. The digestive juices of the patient who sleeps on his belly will therefore bathe the anterior wall of his duodenum ; and the juices of the patient who sleeps on his back will (though to a lesser extent because of the posterior tilt) bathe the posterior duodenal wall. This hypothesis may be criticised on the grounds that the gut is not a flaccid gutter, that its walls are normally in apposition, and that stagnant puddles of secretion are therefore unlikely to form. Yet at laparotomy the duodenum is usually found to be uncollapsed, and peristalsis is less noticeable there than elsewhere in the small gut. More difficult to counter is the suggestion that people do not know in what position they sleep-they know only the position in which they fall asleep. During the night, if advertisements are to be believed, vast amounts of energy are expended in twisting and turning. Nevertheless, careful observations on sleeping hospital patients reveal that major movements involving complete change of posture are made, on the average, some three or four times only ; and usually the patients revert quite soon to their " favourite " sleeping position. Most patients become more restless towards morning, but quite a number-particularly women-lie log-like all night in one
Although the German classification is not appropriate for pneumoconiosis in coalminers, and differs from the classification used in this country, a detailed survey here would probably also show reasonable general agreement between radiographic and pathological observations. Safety in Mines Research Establishment Ministry of Fuel and Power, Portobello Street, Sheffield, 1.
G. NAGELSCHMIDT.
RUPTURE OF DUODENAL STUMP AFTER
GASTRECTOMY Henson’s SIR,—Mr. paper (March 19) draws attention to afferent-loop obstruction as a dangerous complication of a Polya partial gastrectomy. The successful result in his case emphasises the importance of his early and accurate diagnosis of this complication, which is gradually
becoming more widely recognised. With regard to his conclusions I would suggest that, in addition to careful clinical and radiological examinations, the gastric remnant should alwaysbe aspirated with a Ryle’s tube, when afferent-loop obstruction is suspected. Absence of bile in the aspirations will confirm that the afferent loop is obstructed. This simple test can be performed in a few minutes in the ward, and may give useful results, particularly at times when the clinical signs are indefinite and radiological facilities are not immediately available. Ilford, Essex.
R. P. WARREN.’ WARREN.
interested to read Mr. Henson’s article. not sure that a distended afferent loop per se will cause the blowing of a duodenal stump, I feel that it may contribute to this catastrophe. With an imperfect duodenal suture-line, afferent-loop distension could conceivably hasten the breakdown of the closure and add to the violence of the burst. For four years I have been performing a Roux-en-Y anastomosis in the Polya type of gastrectomy for duodenal ulcer. This operation results in deviation of the afferent loop from the gastro-intestinal anastomosis, and is undertaken to prevent the post-gastrectomy
SIR,—I
Although
was
I
am
,
,
Triger, K. Lancet, 1954, i, 574. Fletcher, C. M. Ibid, p. 626. 3. Worth, G., Nerreter, W. Beitr. SilikForsch. 1954, 30, 3.
J. EWART SCHOFIELD.
position. Sleeping posture varies considerably with age : the young sleep more often on their bellies than do the old, and more older people-perhaps because of fat bellies and less adaptable vertebral columns-sleep on their backs. Nevertheless, the most common position in all age-groups is on the right side. Slightly less common are those who sleep on their left sides. Comparatively few persons sleep on their backs, and even fewer sleep on their bellies. 100 patients who had had anteriorly perforated duodenal ulcers (confirmed at laparotomy) were first investigated. Those who had returned home were sent a questionnaire concerning their position during sleep, and the others were questioned verbally. Many were unable to make dogmatic statements, so the words always, usually,"""sometimes," and " never " were used in estimating the frequency of the four positions (right side, left side, back, or belly). When allowances had been made for intermediate positions, the "
fmdinea
were as
follows
"
:-
1. 2.
1.
Schofield, J. E., Anderson, P. St. G.
Brit. med. J. 1953, ii, 598.
sense is neither disease nor a menace. On the other hand, once a neoplasia is established, its destination may be earmarked, biologically, from the
We stated that a point incidental to the Roux-en-Y type of anastomosis was that the duodenal contents pass uninterrupted into the jejunum, thus diminishing the risk of a blown duodenal stumpy My experience with the Roux-en-Y anastomosis has been that, while a small number of minor duodenal leaks have been encountered (about the seventh day with little inconvenience to the patient), there have been This no cases of catastrophic burst duodenal stump. an may prove important advantage. My experience supports the claim that a distended afferent loop is an important factor in rupture of a duodenal stump.
syndrome.
a
one way or the other, near be occasion impossible. A variety of physiomay and may be found in sections patterns pathological logical from different areas of the same breast. These are often interpreted as stepping-stones to disaster, but presumably, could be tissue reactions to a varying chemical status. F. D. SANER.
start; yet histological confirmation, on
Victoria Hospital, Swindon, Wiltshire.
PNEUMOCONIOSIS 1
SIR,—Dr. Triger has commented
on
the lack of
com-
PERFORATED DUODENAL ULCER AND SLEEPING POSITION
pneumoconiosis diagnoses during life with parisons post-mortem findings, and Dr. Fletcher 2 has subsequently drawn attention to the observer error in pathological of
SIR,—Few will dispute that hyperchlorhydria is an important factor in duodenal ulceration. The following investigation was suggested by the possibility that gastric and duodenal night secretions, collecting at the most dependent portion of that part of the gut, might there cause ulceration. The most dependent portion will, of course, vary with the patient’s position ; but changes of position are very much less at night, and so it seemed reasonable to expect some relationship between sleeping posture and the site of ulceration.
assessment. This problem of comparing diagnoses post-mortem findings in silicosis has studied in Germany.
intra vitam with been repeatedly
Worth and Nerreter 3 have analysed the data for 327 cases of silicosis confirmed by necropsy. The degree of silicosis was based on the older classification into stages I, II, and III. In 83% of the cases there was agreement between clinical and post-mortem findings for the degree of silicosis found. Taking the necropsy findings as correct, the clinical results overestimated the disease in 8% of the cases and underestimated it in another 8%. The overestimates occurred chiefly in stages O-II and the underestimates in stage III.
One obvious objection is that the lie of the stomach is very variable ; for this reason gastric ulceration was ignored throughout the investigation. The position of the duodenum is also variable, but the differences are comparatively slight. The anterior surface of the first part of the duodenum nearly always passes transversely from left to right with a slight tilt superiorly and posteriorly. The digestive juices of the patient who sleeps on his belly will therefore bathe the anterior wall of his duodenum ; and the juices of the patient who sleeps on his back will (though to a lesser extent because of the posterior tilt) bathe the posterior duodenal wall. This hypothesis may be criticised on the grounds that the gut is not a flaccid gutter, that its walls are normally in apposition, and that stagnant puddles of secretion are therefore unlikely to form. Yet at laparotomy the duodenum is usually found to be uncollapsed, and peristalsis is less noticeable there than elsewhere in the small gut. More difficult to counter is the suggestion that people do not know in what position they sleep-they know only the position in which they fall asleep. During the night, if advertisements are to be believed, vast amounts of energy are expended in twisting and turning. Nevertheless, careful observations on sleeping hospital patients reveal that major movements involving complete change of posture are made, on the average, some three or four times only ; and usually the patients revert quite soon to their " favourite " sleeping position. Most patients become more restless towards morning, but quite a number-particularly women-lie log-like all night in one
Although the German classification is not appropriate for pneumoconiosis in coalminers, and differs from the classification used in this country, a detailed survey here would probably also show reasonable general agreement between radiographic and pathological observations. Safety in Mines Research Establishment Ministry of Fuel and Power, Portobello Street, Sheffield, 1.
G. NAGELSCHMIDT.
RUPTURE OF DUODENAL STUMP AFTER
GASTRECTOMY Henson’s SIR,—Mr. paper (March 19) draws attention to afferent-loop obstruction as a dangerous complication of a Polya partial gastrectomy. The successful result in his case emphasises the importance of his early and accurate diagnosis of this complication, which is gradually
becoming more widely recognised. With regard to his conclusions I would suggest that, in addition to careful clinical and radiological examinations, the gastric remnant should alwaysbe aspirated with a Ryle’s tube, when afferent-loop obstruction is suspected. Absence of bile in the aspirations will confirm that the afferent loop is obstructed. This simple test can be performed in a few minutes in the ward, and may give useful results, particularly at times when the clinical signs are indefinite and radiological facilities are not immediately available. Ilford, Essex.
R. P. WARREN.’ WARREN.
interested to read Mr. Henson’s article. not sure that a distended afferent loop per se will cause the blowing of a duodenal stump, I feel that it may contribute to this catastrophe. With an imperfect duodenal suture-line, afferent-loop distension could conceivably hasten the breakdown of the closure and add to the violence of the burst. For four years I have been performing a Roux-en-Y anastomosis in the Polya type of gastrectomy for duodenal ulcer. This operation results in deviation of the afferent loop from the gastro-intestinal anastomosis, and is undertaken to prevent the post-gastrectomy
SIR,—I
Although
was
I
am
,
,
Triger, K. Lancet, 1954, i, 574. Fletcher, C. M. Ibid, p. 626. 3. Worth, G., Nerreter, W. Beitr. SilikForsch. 1954, 30, 3.
J. EWART SCHOFIELD.
position. Sleeping posture varies considerably with age : the young sleep more often on their bellies than do the old, and more older people-perhaps because of fat bellies and less adaptable vertebral columns-sleep on their backs. Nevertheless, the most common position in all age-groups is on the right side. Slightly less common are those who sleep on their left sides. Comparatively few persons sleep on their backs, and even fewer sleep on their bellies. 100 patients who had had anteriorly perforated duodenal ulcers (confirmed at laparotomy) were first investigated. Those who had returned home were sent a questionnaire concerning their position during sleep, and the others were questioned verbally. Many were unable to make dogmatic statements, so the words always, usually,"""sometimes," and " never " were used in estimating the frequency of the four positions (right side, left side, back, or belly). When allowances had been made for intermediate positions, the "
fmdinea
were as
follows
"
:-
1. 2.
1.
Schofield, J. E., Anderson, P. St. G.
Brit. med. J. 1953, ii, 598.