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Some Physiologic Aspects of the Surgical Treatment of Duodenal Ulcer
SOME PHYSIOLOGIC ASPECTS OF THE SURGICAL TREATMENT OF DUODENAL ULCER JAMES
T.
PRIESTLEY
FOR a number of years duodenal ulcer has been the subject of considerable study by the laboratory investigator, clinician and surgeon. As a result, knowledge of this lesion as it occurs experimentally as well as clinically is far more complete now than in former years. Unanswered questions still remain, however. As yet no treatment has been developed, either medical or surgical, which can be called ideal. Naturally, practicing physicians and surgeons are most interested in the treatment of this lesion .. Obviously, intelligent treatment of duodenal ulcer presupposes familiarity with the etiology of ulcer, the normal physiology of the stomach and duodenum, the pathologic physiology associated with ulcer and the alterations of normal functions produced by various types of surgical procedures.
ETIOLOGY
During a number of years a wealth of evidence has been accumulated which attests the importa!,!ce of the factor of acidity in the causation of duodenal ulcer. Experimental as well as clinical observations substantiate the fact that ~he ordinary type of duodenal ulceration uniformly is associated with elevation of gastric acidity. In fact, probably one should go so far as to say that abnormal and consistent increase of gastric acidity is the cause of duodenal ulcer rather than to continue saying that the cause 'of the lesion is unknown. Although acceptance of this statement as a fact. is helpful in the. tEeatment of ulcer, it does not by any means completely solve the problem. More important would be accurate knowledge as to why gastric acidity is elevated. At present most all therapy of duodenal ulcer is directed toward elimination of excess acidity. Medical treatment is directed toward eradication of extraneous factors which might stimulate gastric secretion and toward neutralizatiop of acid after it has been produced. Surgical treatment is directed toward elimination of the acid-producing glands, diversion of gastric secretion from the duodenum or elimination of the neurogenic element of gastric secretion by section of the vagus nerves. In other words, at present there is no direct approach to elimination of the factor or factors primarily responsible for the initial increase of gastric acidity and for the prolongation of increase seen in cases of duodenal ulcer. Closely coupled with the factor of acidity in the etiology of duodenal ulcer are the normal defense mechanisms which prevent ulcera905
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tion of the duodenum from occurring in all individuals. It seems possible that certain deficiencies may exist in the normal resistance to the action of gastric juice exhibited by the duodenal mucosa of those in whom ulceration of the duodenum develops. It is well known, for example, that some individuals may have hyperacidity for years and yet an actual ulcer of the duodenum will not develop. Is this because their. defense me<;hanis:qlS are more active than are the mechanisms of those in whom ulceration occurs? Knowledge of the normal defense mechanisms is not so complete as one might des¥,e bllt~ni()ng the factors whicb. are commonly considered import~nt'; in this regard might be mentioned the secretion of mucus, then9rmal flow of hile andpancl'eatic j\lice into th() duodenum, the normal vitality (adequate cir~ulation ap.d so forth) of the duodenal mucosa and the secretion of succus eI}tericus. In addition, consideration' m~~t be given the normal regulatoly'methanisms which ordinarily terminate that stimulati9n of gastric seCreti9D. which is associated with ingestion of food. Of' tPe other etiologic factors which should be mentioned, perhaps the most important One is a local factor. It seems apparent that there should be some reason why ulceration occurs so consistently in approximately the same portion Qf the duodenum, both experimentally and clinically. It seems likely that local trauma produced by direct emptying of the stomach into this portion of the duodenum, as suggested by Mann some years ago, may constitute such a local factor. It is known that inflamed tissues, such as those subjected for some time, to the action of dilute acids, are definitely more subject than normal tissues to ulceration as a result of trauma. The neurogenic factor, long recognized as one of importance in the etiology of duodenal ulcer, probably acts through its effect on the gastric mucosa in general and the secretory cells of the gastric mucosa in :particular. It is also possible that this factor is responsible for effeCts· more' Clirect than that just mentioned. Infection and local avas~~larity probably are of 'little iIIlPortance in the average case. NORM4L' PQ)'SIQLOf;Y ,
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NQrmallygastric secretion occurs in three phases, each of whicb is self-limited, is responsible for only a portion of the total gastric secretion associated' with the ingestion of food and is blended with the preceding or subsefluent phase or with both, as the case may he, to effect normal gastric participation ill digestion. The initial or psychic phase of gastric secretion is mediated through neurogenic pathways (vagus nerves) and is stimulated by sensations from the
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The second, or gastric, phase of secretion begins with the entrance of food into the stomach. Certain foods, such· as proteins, cause a greater response than others, such as fats or carbohydrates. This phase is largely chemical in nature, although the mere presence of food in the stomach stimulates a small amount of secretion through mechanical means. It is commonly accepted that the stimulus to gastric secretion in this phase of the process is a humoral agent called "gastrin," produced by the prepyloric mucosa. It is known clinically that any type of gastric resection which does not include removal of the prepyloric gastric mucosa, in the treatment of duodenal ulcer, is followed by less favorable results than when this site is resected. Normally the gastric, or second, phase of secretion decreases in significance as the stomach empties. Proper motor function is thus of importance in the normal regulation of gastric secretion. The third, or intestinal, phase of gastric secretion supervenes as food leaves the stomach and enters the intestine. This is the least powerful but probably the most prolonged phase, as it is stated that it may last from three to nine hours. Presumably during this phase certain processes are initiated which tend to terminate or, at least, to inhibit gastric secretion. Ivy and his co-workers have detected in the intestinal tract a substance which they named "enterogastrone" and in the urine another which they called "urogastrone." Clinical use of these agents in the medical treatment of duodenal ulcer is in the investigative stage at this time. Although secretion of gastric juice in the human being is said to be continuous, varying largely of course in amount, depending on existing stimuli, the amount of secretion at night is small in the normal individual. In addition to thinking of acidity only as related to the stomach, one must consider also the hydrogen ion concentration of the duodenal contents, as obviously the duodenum is the site of ulceration. Kearney has observed that in the normal individual the pH of the duodenal contents is above 4.0, the concentration at which free acid occurs, 80 per cent of the time. If the pH of the duodenal contents drops below 4.0 when the stomach empties a portion of its contents into the duodenum, it is only a matter of a few minutes until the pH returns to 4.0 or above. Such prompt regulation of the pH of the duodenal contents requires normally active neutralizing mechanisms. As mentioned previously, stimulation of the vagus nerves causes secretion of gastric juice. These nerves appear to be motor to the wall of the stomach and inhibitory to the pylorus. In contrast, stimulation of the sympathetic nerves to the stomach causes mainly a flow of alkaline juice from the prepyloric glands; this juice consists mostly of mucus and is low in peptic power. Few if any acid-secreting glands are located in the prepyloric portion of the stomach. Likewise the number of these glands is greatly reduced in the cardia and somewhat
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decreased along the angle·· of the stomach on the lesser curvature. The sympathetic fibers presumably inhibit gastric motility but are motor to the pylorus. PATHOLOGIC PHYSIOLOGY
As mentioned previously, hyperacidity is considered to be a constant forerunner of duodenal ulcer. Commonly, hyperacidity is manifested in degree of acidity, as estimated after a test meal, as well as in total amount of acid secreted in twenty-four hours. The cause of increased acidity is not fully known. Neurogenic stimuli may play a large part but likewise chemical factors, faulty neutralization and deficient regulatory mechanisms of gastric secretion may be significant. Thus, with the occurrence of gastric hypersecretion more gastric contents of a lower pH must be neutralized by the duodenum if the acidity of the duodenal contents is to be maintained at a normal value. This is not accomplished in cases of duodenal ulcer. Kearney has demonstrated that in the presence of duodenal ulcer the pH of the duodenal contents is, approximately reversed from that which exists in the normal individual; namely, that 80 per cent of the time, when ulcer is present, the pH of the duodenal contents is below 4.0, the concentration at which free acid appears. When gastric contents enter the duodenum under these circumstances the pH drops well below 4.0 and, instead of returning promptly to a value of 4.0 or higher, it is slow in reaching this value. As a result, increased acidity of duodenal contents occurs which predisposes to the development of an ulcer and militates against its healing once it is present. Medical measures normally are directed toward reducing this duodenal acidity, and such treatment may be sufficiently effective to result in healing. If, however, these measures are discontinued and the same factors are present which initially caused the augmented acidity, ulceration may occur. Certain surgical procedures may decrease the acidity of the duodenal contents by a mechanical and, .therefore, more lasting method; however, simultaneous increase in acidity of the jejunal contents usually occurs if gastrojejunal anastomosis is established and secretion of free acid persists in the stomach. Motor function of the stomach may become altered slightly or markedly when a duodenal ulcer develops. Increased tone in the prepyloric portion of the stomach is a common roentgenologic observation and increased muscular irritability is a frequent occurrence. Delayed emptying of the stomach may be caused by inflammatory reaction in the region of the lesion or by actual sclerotic obstruction of the duodenum. It is remarkable at times how the gastric musculature will respond to an increased demand on its efforts and will continue to empty the stomach adequately despite definite duodenal narrowing. Varying degrees of obstruction may exist without symp-
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tomatic evidence and may be detected only by roentgenologic means or by use of a test meal for motor function. Failure of the stomach to empty properly may be intermittent. The chronically obstructed stomach often becomes large and the surgeon, in planning any operation, should anticipate its return to normal size after relief of obstruction. INDICATIONS FOR SURGICAL TREATMENT
It is generally agreed that medical treatment should be instituted in all cases of duodenal ulcer except those in which certain complications are present. Our experience at the Mayo Clinic indicates that approximately 85 per cent of all patients with this condition can be treated medically. Complications which are considered to indicate the desirability of surgical b'eatment, and which will be discussed only brieHy, may be listed as primary or secondary. In the former group are included hemorrhage, obstruction; perforation, failure of medical management and any doubt as to the benignity of the lesion. Hemorrhage may present itself either in the form of active, acute, massive hemorrhage or as a history of recurrent hemorrhages without active bleeding at. the time the patient is examined. Opinion differs as to the type of treatment advisable for acute massive hemorrhage. In the past treatment was always conservative but in recent years some surgeons have favored emergency surgical treatment. In general it may be stated that the majority of patients who have massive hemorrhage from duodenal ulcer and are less than forty-five years of age respond favorably to medical manllgement. On the contrary, the risk of medical management is increased definitely in the group of patients who are more than forty-five years of age. At present it is our practice to institute medical treatment in all· cases in which massive bleeding from duodenal ulcer occurs. If, after medical treatment has been continued for forty-eight hours, there is still evidence of continued or recurrent bleeding, it is our opinion that immediate surgical intervention is desirable. In other words, the patient is given an opportunity to respond to medical treatment, but if the response is not favorable in forty-eight hours we believe that there should be no further delay in surgical treatment. For the patient who has had several episodes of bleeding one is always a little more inclined to suggest surgical treatment. This is especially true if bleeding occurs under. ordinary circumstances, when the patient has been taking at least fairly good care of himself. Medical treatment which failed to prevent hemorrhages in the past hardly can be considered adequate to prevent hemorrhage in the future. Obstructive lesions caused by duodenal ulcer may be either inHammatory or sclerotic in nature. The inHammatory type of obstructive lesion usually is seen during a subacute exacerbation of symptoms,
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Under proper medical treatment, symptoms of obstruction generally disappear in a week or ten days. It is doubtful, however, whether more than one or two such episodes should be treated medically because they are likely to recur and cause sclerotic narrowing of the duodenum. When a definite cicatricial type of obstructive lesion results, the problem becomes largely mechanical in nature; then there is little to offer but surgical treatment. Perforation by a duodenal ulcer may be either a subacute or an acute process. All agree that acute perforation of a duodenal ulcer constitutes a surgical emergency. The subacute perforating duodenal ulcer generally is one of pronounced activity, causing varying degrees of penetration through the wall of the duodenum. In the advanced case the entire thickness of the duodenal wall has been eroded and the base of the crater consists of adjacent tissue, usually pancreas. When an ulcer of such pronounced activity is present it is unlikely that medical management will result in satisfactory cure. Failure of medical management to relieve symptoms of ulcer long has constituted an indication for surgical treatment. Care must be exercised, however, in determining just when failure of medical management has occurred. One should be confident that an adequate regimen has been followed. Occasionally uncertainty will exist regarding the exact diagnosis in a case of duodenal ulcer. This occurs most often when the lesion is situated at the pylorus and the roentgenologist is unable to say whether it is actually in the duodenum or on the gastric side of the pylorus. A small carcinoma in this vicinity may closely simulate a duodenal ulcer. If any doubt exists as to the benignity of the lesion, surgical exploration should be advised. Thus, if an obstructing lesion at the outlet of the stomach is thought to be a duodenal ulcer, but if the gastric acidity is low and perhaps free hydrochloric acid is absent, exploration should be performed. Besides these primary indications for surgical treatment of duodenal ulcer, there are certain factors of secondary importance, the presence of which tends to favor surgical intervention. These include: a very unfavorable economic status, which virtually prevents the patient from making adequate trial of medical management; the unco-operative nature of a given patient whereby the dietary regimen is not followed; excessive gastric acidity with a value of free hydrochloric acid possibly of 80 or more (Topfer's method); a history of duration for many years and symptoms of marked severity. While no one of these secondary factors alone should be considered to constitute a definite indication for operation, when two or more of them exist in the same case, thought should be given to the advisability of operation.
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GASTRO-ENTEROSTOMY
Physiologic Considerations.-Complete diversion of the gastric contents from the duodenum by a satisfactorily functioning gastroenteric stoma results in marked change in the pH of the duodenal contents. Under these circumstances the duodenal contents constantly are neutral or alkaline and, therefore, the duodenal ulcer heals in virtually every case. Unfortunately, however, the amount of gastric secretion is not reduced by this operation; only the site at which it enters the intestine is changed from the duodenum to the jejunum. The beneficial factor, from the viewpoint of neutralization or dilution of the gastric contents, is that most of the duodenal juices pass either into the stomach or directly along the jejunum where it is joined to the stomach, provided a short jejunal loop has been used in making the anastomosis. Undoubtedly this behavior of duodenal juices COnstitutes a factor of importance in the prevention of jejunal ulceration. When an ulcer develops after gastro-enterostomy it almost always occurs in the distal loop of jejunum in proximity to the stomach. At this site probably the greatest trauma from gastric emptying and the highest acidity occur. In addition to changing the acidity of the duodenal and jejunal contents gastro-enterostomy alters the motor function of the stomach in that it permits satisfactory emptying of the stomach despite obstruction in the first portion of the duodenum. Thus existing duodenal obstruction is eliminated as a factor of significance. Indications.-Although one hears many words of condemnation for gastro-enterostomy, it cannot be denied that many patients have experienced an eminently satisfactory result after this operation. It seems that this fact should be kept in mind because, if this operation is performed with proper indication and its technical execution is correct, good results still may be expected in a large majority of cases True, the possibility of occurrence of jejunal ulcer always remains, but that possibility also exists, to a less extent, after gastric resection. It should be remembered that, in the hands of the average surgeon, gastro-enterostomy entails a definitely lower operative risk than does gastric resection. Castro-enterostomy may be performed as an operation of choice or at times as one of expediency. The patient who qualifies in the former category would be, as a rule, of advanced years; would constitute a poor surgical risk; would have a chronic lesion of long standing, perhaps causing obstruction because of sclerotic changes; would have relatively low gastric acidity; would present a single lesion and no appreciqble associated gastritis and would exhibit a minimal neurogenic factor. At times gastrojejunostomy may be employed in the absence of many of the conditions just mentioned if the technical aspects of gastric resection involve too great difficulty or hazard.
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Such may be the case in dealing with an ulcer deeply placed in a shortened duodenum which permits neither removal of the ulcer and satisfactory closure of the duodenal. stump without jeopardizing the common bile duct nor section of the duodenum immediately distal to the pylorus and satisfactory closure of the duodenal stump. This type of lesion in an obese individual with a small, high-lying stomach and deeply placed duodenum, makes resection more difficult and hazardous and, therefore, may make advisable something less desirable than the surgical procedure of theoretic choice. As the surgeon's experience increases, technical considerations of this type become less of a factor in his choice of operative procedure. Technical Considerations.-The many technical details involved in the establishment of a gastro-enteric stoma will not be discussed, but only a few points will be mentioned which seem of particular importance for the satisfactory postoperative function of gastrojejunal anastomosis. Likewise, only one type of gastrojejunostomy will be considered. The placing of the stoma is important. It should be neither too proximal nor too distal in the stomach; neither should it be too high nor too smalL While there is more than one way of making a gastrojejunal stoma that will permit satisfactory gastric motor function, the preferred type is as follows: The stoma is placed on the posterior wall of the stomach and is extended almost from the lesser curvature down to the greater curvature in' a line ru~ming approximately from the patient's right shoulder to his left foot, with the proximal jejunal loop fixed to the lesser curvature of the stomach and the distal loop joined to the greater curvature. The point at which the distal jejunal loop. is attached to the greater curvature of the stomach should be directly below the angle of the lesser curvature. One should remember that an enlarged, obstructed stomach will decrease in size after relief of the obstruction with corresponding decrease in size of the gastro-enteric stoma. Two or three rows of sutures may be used. Fine suture material is preferred. The stoma in the jejunum should be placed directly opposite the mesenteric border. Less than 0.5 cm. of stomach or jejunum should be inverted into the gastro-enteric lumen, particularly at the point at which the distal loop of jejunum leaves the stomach. The retrocolic type of anastomosis is preferred. The transverse mesocolon should be sutured to the gastric wall at least 2 cm. removed from the site of anastomosis around the entire stoma. The surgeon must be certain that these sutures actually are placed in the gastric wall in the region of the greater curvature and not in the gastrocolic omentum. This requires that several sutures be passed through the gastrocolic omentum and into the anterior gastric wall at the lower angle of the anastomosis. A short proximal jejunal loop should be used.
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one just short enough, perhaps 8 to 10 cm. in length, to permit approximation of the jejunum to the lesser curvature of the stomach without tension, yet without appreciable redundancy. At the conclusion of the operation the distal loop of jejunum should be placed so that it lies to the patient's left in the region of the root of its mesentery. GASTRIC RESECTION
Physiologic Considerations.-The primary purpose of all types of gastric resection performed for duodenal ulcer is to eliminate the factor of acidity in the genesis of ulcer by removal of a major portion of the acid-secreting gastric mucosa. This involves simultaneous eradication of most of the gastric ferments and of a large part (two thirds to four fifths) of the stomach, with resultant decrease in capacity of the stomach as well as decrease in the gastTic phase of digestion. Obviously S4ch an operation entails greater physiologic and anatomic change than is ideal. The small residual gastric capacity which results is responsible occasionally for undesirable postoperative symptoms. The emptying time of the stomach is decreased, which may cause symptoms, and food is permitted to enter the small intestine, duodenum or jejunum, as the case may be, without the normal amount of preliminary change. If gastrojejunal anastomosis. is established, as is the common practice, the amount of the digestive juices which normally are secreted and excreted into the duodenum may be decreased, as has been suggested by Wangensteen and studied by Kolouch. AfteT restoration of gastro-intestinal continuity by gastrojejunal anastomosis the pH of the duodenal contents remains neutral or alkaline and the duodenal ulcer heals in all cases if, for any reason, it is not removed; however, the ulcer almost always is removed at the time of resection. The subsequent danger then, as with gastroenterostomy, is the possibility of jejunal ulceration. This, of course, occurs infrequently if the amount of stomach removed is adequate to eliminate free hydTochloric acid from the gastric contents. The most physiologic type of resection, and the one which I prefer and use whenever feasible, is the Billroth I type. In this procedure the stomach is rejoined to the duodenum after gastric resection. Physiologically this procedure is sounder than certain others in that it permits food to pass from the stomach to the duodenum as it normally does, although the food is not prepared as completely before entering the duodenum as it was prior to operation. One may anticipate, however, virtually normal stimulation of pancreatic and biliary secretory activity. Obviously a jejunal ulcer cannot occur at the site of anastomosis; should ulcer occur in the duodenum the patient is no worse off than he was prior to operation. Resection, wth anastomosis
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of this type, is simpler to perform and entails fewer suture lines than a Billroth II type of operation. Likewise motor function is uniformly satisfactory and the so-called dumping syndrome does not occur. The pH of the duodenal contents is elevated because of reduction in the gastric secretory surface and, consequently, recurrent duodenal ulcera. tion is unlikely. Indications.-Indications for gastric resection will vary with one's current opinion regarding the indications for vagotomy. My view regarding vagotomy is conservative at the present time, for reasons that will appear later. Until vagotomy has had time to prove itself, therefore, gastric resection probably should be used in approximately five out of six cases of duodenal ulcer, at least in the type of cases seen in my experience. It is apparent from previous remarks that resection is not considered an ideal procedure for treatment of duodenal ulcer and it is possible that as time passes this procedure may be supplanted gradually by one or more forms of medical or surgical treatment. At present the ideal patient for gastric resection would be a man of middle age, in good general condition, who had failed to obtain relief despite careful and prolonged adherence to a medical regimen, whose gastric acidity was high, who perhaps had experienced recurrent hemorrhages and who had an active lesion for which resection would not be unduly difficult or hazardous. The presence of multiple ulcers and associated gastritis, as well as of a large neurogenic element, would favor resection rather than conservative operation; however, none of these factors makes for a favorable postoperative result. Technical Considerations.-As mentioned previously, the Billroth I type of anastomosis is preferred to the Billroth II. More specifically, preference is for the Shoemaker modification of the Billroth I type, in which resection of the stomach is carried higher along the lesser curvature than the greater curvature and the end of the stomach, after closure of the lesser curvature to the desired point, is anastomosed directly with the end of the duodenum. To accomplish this operation one must have an adequate amount of duodenum distal to the ulcer that can be mobilized with a good blood supply. Anastomosis must be accomplished without tension and without limitation of resection of the desired amount of stomach. The end of the gastric stump is so formed by appropriate closure of the lesser curvature, that its size corresponds with that of the duodenum. The amount of stomach and duodenum inserted into the gastroduodenal stoma should be small in order that an adequate gastric outlet may be maintained. Although crushing clamps may be used, my preference is for the so-called open anastomosis performed by the use of rubber-covered Doyen forceps. In a Billroth II type of resection it has been well demonstrated that short-loop, retrocolic .anastomosis is followed by results superior to
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those obtained when· long-loop, antecolic anastomosis is employed, although some surgeons advocate the latter type. This latter type, which is technically easier to perform, at times may be used for expediency if the patient is fat, the transverse colon short and thick and the stomach is small and in a high position. Entero-anastomosis between the jejunal loops is unnecessary and undesirable. One may anastomose the entire end of the stomach with the jejunum, or only a part of it after closure of the portion bordering the lesser curvature, according to the method of Hofmeister; the latter procedure is the favored one. None of the prepyloric portion of the stomach should be permitted to remain. Removal of the duodenal ulcer itself is unnecessary, although some state otherwise, so long as satisfactory closure of the duodenal stump is obtained. In practice the ulcer is removed almost invariably. Satisfactory closure of the duodenal stump is most important. Likewise it is essential that there be no angulation or other factor which might interfere with free emptying of the proximal jejunal loop, as increased intraluminal duodenal pressure predisposes to leakage from the duodenal stump. The same technical points discussed in connection with gastro-enterostomy apply in establishing gastrojejunal anastomosis after gastric resection; namely, approximation of the jejunum and the stomach, direction of jejunal loops, length of proximal jejunal loop, suturing the transverse mesocolon well back from the anastomosis and so forth. VAGOTOMY
Physiologic Aspects.-Complete section of the vagus nerves abolishes the psychic phase of gastric secretion and other neurogenic influences on the gastric mucosa. As a result the amount of gastric secretion (gastric enzymes as well as acid) and degree of acidity of the gastric juice are decreased. Usually vagotomy does not result in anacidity or complete absence of free hydrochloric acid, because the activity of the gastric and intestinal phases of gastric secretion persist. Nevertheless, reduction in amount of gastric secretion and in degree of acidity is definite. Lester Dragstedt, who has been largely responsible for the present-day clinical use of bilateral vagotomy in the treatment of duodenal ulcer, emphasizes the marked reduction in night secretion which occurs after this operation. Simultaneously there is a decrease in the motor function of the stomach. This may be manifest clinically, provided gastro-enterostomy is not performed simultaneously, by gastric retention in certain cases in which there were no symptoms of retention preoperatively; in fact, even in some cases in which a gastrojejunal stoma is established temporary gastric retention may occur. What the ultimate (five to fifteen years) results will be on the human stomach from a secretory point of view, as well as
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from that of motor function, is not known and this fact, in my opinion, constitutes one of the chief reasons why bilateral vagotomy should not be performed in a widespread manner at present. For example, it takes some few years, as a rule, for Hirschsprung's disease to cause pronounced enlargement of the colon. In a certain percentage of dogs subjected to bilateral transthoracic vagotomy there has been a return of gastric acidity to its preoperative value five years after operation and, in addition, some of the animals have had a greatly dilated, atonic stomach at that postoperative date. The early (two to three years) postoperative results in human beings apparently have been satisfactory in numerous cases; however, in some cases they have not been good. The vagus nerves do not supply sensory fibers to the stomach, as is evidenced by the fact that intra gastric distention after bilateral vagotomy causes distress. The importance of vagal stimuli to the motor function of the remaining portion of the intestinal tract is not completely understood. From the standpoint of immediate clinical results, vagal stimuli do not appear to be too important. Likewise the significance of vagal stimuli to the secretory and excretory functions of the accessory glands of digestion is not completely known but apparently· such stimuli are not essential, according to impressions gained from observations in early postoperative clinical cases. Indications.-At present probably no two gastric surgeons would offer an identical group of indications for vagotomy in the treatment of duodenal ulcer. One's selection of patients for vagotomy depends, as mentioned previously, on the degree of one's current acceptance of .this procedure for use routinely in the surgical management of duodenal ulcer. As mentioned previously, my opinion is conservative, as I believe that this operation, although promising, should prove itself over a period of five to ten years before it is permitted to replace old and tried methods which, it is known, will give good results in a high percentage of cases. The work of Dragstedt is outstanding; I believe that the operation should be proved in hands such as his rather than by a large number of isolated surgeons over the country, who, of necessity, will have fewer and less well-controlled cases. With this preamble it is apparent that at this time I can present only my personal viewpoint regarding the indications for vagotomy and that these views should not be misinterpreted as facts. In general, 1 have considered the operation indicated if there is nothing else to offer the patient which can give a high assurance of a good result. Thus, in the case of a man twenty years of age, perhaps of Jewish extra<;tion, who is extremely nervous and who suffers from excessive gastric acidity and long-standing symptoms so severe that almost constant hospitalization is required, bilateral vagotomy may be a proper procedure. It is known that in this type of case gastric resec-
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tion, even though extensive, may be followed by formation of jejunal ulcer. In general, then, I believe that at this time the operation should be reserved for the exceptional type of patient who has duodenal ulcer. In contrast, indications for vagotomy in the treatment of jejunal ulcer are perhaps wider; however, this is not the type of lesion under discussion. Gastric retention may occur after transthoracic vagotomy performed for duodenal ulcer, even though preoperatively there was no indication of gastric obstruction as shown by clinical or laboratory investigation. Such retention may be severe enough to require gastroenterostomy. Because of this fact transthoracic vagotomy seldom seems indicated in the treatment of duodenal ulcer. If this viewpoint is accepted, transabdominal vagotomy performed in association with gastro-enterostomy would constitute the alternative and more desirable procedure. Evaluation of late results of this method of treatment will require the lapse of a number of years. The abdominal approach presents the advantage of permitting direct examination of the lesion and exploration of the entire abdomen. It has the disadvantage, until the surgeon has gained considerable experience, of making complete resection of all branches of the vagus nerves somewhat less certain. Technical Aspects.-A prerequisite to the performance of vagotomy is accurate knowledge of the anatomic location and distribution of the fibers of the vagus nerves, both above and below the diaphragm. Failure to section all fibers of these nerves can lead only to confusion and unsatisfactory results. If a transthoracic approach is employed, resection of a generous portion of the left eighth rib affords fine exposure.· Occurrence of a pathologic process previously in the left side of the thorax adds to the difficulties and, in certain cases, may make a right-sided approach more desirable. A generous portion (preferably 3 cm. at least) of each vagus nerve should be resected and an effort made to prevent realignment of the nerve ends, should regeneration occur. In the abdominal approach a left-sided incision, although it is not. essential, aids in obtaining good exposure of the esophagus. Several inches of esophagus should be cleared and extreme care exercised to perform wide resection of all branches of the vagus nerves. A soft rubber catheter, or a strip of gauze on which caudal traction is made after it is looped around the esophagogastric junction, is helpful in obtaining adequate mobilization and exposure of the esophagus. Mobilization adequate to permit rotation of the esophagus in an arc of at least 180 degrees is essential. All. tissue removed should be examined microscopically to aid in the thoroughness of the operation and in the ready recognition of the fibers of the vagus nerves.
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REFERENCES 1. Dragstedt, L. R. and Owens, F. M., Jr.: Supra-diaphragmatic section of the vagus nerves in treatment of duodenal ulcer. Proc. Soc. Exper. BioI. & Med. 53:152-154 (June) 1943. 2. Dragstedt, L. R. and Schafer, P. W.: Removal of the vagus innervation of the stomach in gastroduodenal ulcer. Surgery. 17:742-749 (May) 1945. 3. Gray, J. S., Wieczorowski, E. and Ivy, A. C.: Inhibition of gastric secretion in man with urogastrone. Am. J. Digest. Dis. 7:513-515 (Dec.) 1940. 4. Ivy, A. C. and Gray, J. S.: Enterogastrone. In: Cold Spring Harbor; symposia on quantitative biology. Cold Spring Harbor, Long Island, New York, The Biological Laboratory, 1937, vol. 5, pp. 405-409. 5. Kearney, R. W.: Studies of the duodenal pH in normal subjects and in patients with duodenal ulcer. Thesis, Graduate School, University of Minnesota, 1940, 83 pp. 6. Kolouch, F., Jr.: Rationale for employment of short afferent loop in gastric resection for peptic ulcer. Thesis, Graduate School, University of Minnesota, 1946. 7. Mann, F. C. and Williamson, C. S.: The experimental production of peptic ulcer. Ann. Surg. 77:409-422 (Apr.) 1923.
T.
PRIESTLEY
FOR a number of years duodenal ulcer has been the subject of considerable study by the laboratory investigator, clinician and surgeon. As a result, knowledge of this lesion as it occurs experimentally as well as clinically is far more complete now than in former years. Unanswered questions still remain, however. As yet no treatment has been developed, either medical or surgical, which can be called ideal. Naturally, practicing physicians and surgeons are most interested in the treatment of this lesion .. Obviously, intelligent treatment of duodenal ulcer presupposes familiarity with the etiology of ulcer, the normal physiology of the stomach and duodenum, the pathologic physiology associated with ulcer and the alterations of normal functions produced by various types of surgical procedures.
ETIOLOGY
During a number of years a wealth of evidence has been accumulated which attests the importa!,!ce of the factor of acidity in the causation of duodenal ulcer. Experimental as well as clinical observations substantiate the fact that ~he ordinary type of duodenal ulceration uniformly is associated with elevation of gastric acidity. In fact, probably one should go so far as to say that abnormal and consistent increase of gastric acidity is the cause of duodenal ulcer rather than to continue saying that the cause 'of the lesion is unknown. Although acceptance of this statement as a fact. is helpful in the. tEeatment of ulcer, it does not by any means completely solve the problem. More important would be accurate knowledge as to why gastric acidity is elevated. At present most all therapy of duodenal ulcer is directed toward elimination of excess acidity. Medical treatment is directed toward eradication of extraneous factors which might stimulate gastric secretion and toward neutralizatiop of acid after it has been produced. Surgical treatment is directed toward elimination of the acid-producing glands, diversion of gastric secretion from the duodenum or elimination of the neurogenic element of gastric secretion by section of the vagus nerves. In other words, at present there is no direct approach to elimination of the factor or factors primarily responsible for the initial increase of gastric acidity and for the prolongation of increase seen in cases of duodenal ulcer. Closely coupled with the factor of acidity in the etiology of duodenal ulcer are the normal defense mechanisms which prevent ulcera905
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tion of the duodenum from occurring in all individuals. It seems possible that certain deficiencies may exist in the normal resistance to the action of gastric juice exhibited by the duodenal mucosa of those in whom ulceration of the duodenum develops. It is well known, for example, that some individuals may have hyperacidity for years and yet an actual ulcer of the duodenum will not develop. Is this because their. defense me<;hanis:qlS are more active than are the mechanisms of those in whom ulceration occurs? Knowledge of the normal defense mechanisms is not so complete as one might des¥,e bllt~ni()ng the factors whicb. are commonly considered import~nt'; in this regard might be mentioned the secretion of mucus, then9rmal flow of hile andpancl'eatic j\lice into th() duodenum, the normal vitality (adequate cir~ulation ap.d so forth) of the duodenal mucosa and the secretion of succus eI}tericus. In addition, consideration' m~~t be given the normal regulatoly'methanisms which ordinarily terminate that stimulati9n of gastric seCreti9D. which is associated with ingestion of food. Of' tPe other etiologic factors which should be mentioned, perhaps the most important One is a local factor. It seems apparent that there should be some reason why ulceration occurs so consistently in approximately the same portion Qf the duodenum, both experimentally and clinically. It seems likely that local trauma produced by direct emptying of the stomach into this portion of the duodenum, as suggested by Mann some years ago, may constitute such a local factor. It is known that inflamed tissues, such as those subjected for some time, to the action of dilute acids, are definitely more subject than normal tissues to ulceration as a result of trauma. The neurogenic factor, long recognized as one of importance in the etiology of duodenal ulcer, probably acts through its effect on the gastric mucosa in general and the secretory cells of the gastric mucosa in :particular. It is also possible that this factor is responsible for effeCts· more' Clirect than that just mentioned. Infection and local avas~~larity probably are of 'little iIIlPortance in the average case. NORM4L' PQ)'SIQLOf;Y ,
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~
NQrmallygastric secretion occurs in three phases, each of whicb is self-limited, is responsible for only a portion of the total gastric secretion associated' with the ingestion of food and is blended with the preceding or subsefluent phase or with both, as the case may he, to effect normal gastric participation ill digestion. The initial or psychic phase of gastric secretion is mediated through neurogenic pathways (vagus nerves) and is stimulated by sensations from the
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The second, or gastric, phase of secretion begins with the entrance of food into the stomach. Certain foods, such· as proteins, cause a greater response than others, such as fats or carbohydrates. This phase is largely chemical in nature, although the mere presence of food in the stomach stimulates a small amount of secretion through mechanical means. It is commonly accepted that the stimulus to gastric secretion in this phase of the process is a humoral agent called "gastrin," produced by the prepyloric mucosa. It is known clinically that any type of gastric resection which does not include removal of the prepyloric gastric mucosa, in the treatment of duodenal ulcer, is followed by less favorable results than when this site is resected. Normally the gastric, or second, phase of secretion decreases in significance as the stomach empties. Proper motor function is thus of importance in the normal regulation of gastric secretion. The third, or intestinal, phase of gastric secretion supervenes as food leaves the stomach and enters the intestine. This is the least powerful but probably the most prolonged phase, as it is stated that it may last from three to nine hours. Presumably during this phase certain processes are initiated which tend to terminate or, at least, to inhibit gastric secretion. Ivy and his co-workers have detected in the intestinal tract a substance which they named "enterogastrone" and in the urine another which they called "urogastrone." Clinical use of these agents in the medical treatment of duodenal ulcer is in the investigative stage at this time. Although secretion of gastric juice in the human being is said to be continuous, varying largely of course in amount, depending on existing stimuli, the amount of secretion at night is small in the normal individual. In addition to thinking of acidity only as related to the stomach, one must consider also the hydrogen ion concentration of the duodenal contents, as obviously the duodenum is the site of ulceration. Kearney has observed that in the normal individual the pH of the duodenal contents is above 4.0, the concentration at which free acid occurs, 80 per cent of the time. If the pH of the duodenal contents drops below 4.0 when the stomach empties a portion of its contents into the duodenum, it is only a matter of a few minutes until the pH returns to 4.0 or above. Such prompt regulation of the pH of the duodenal contents requires normally active neutralizing mechanisms. As mentioned previously, stimulation of the vagus nerves causes secretion of gastric juice. These nerves appear to be motor to the wall of the stomach and inhibitory to the pylorus. In contrast, stimulation of the sympathetic nerves to the stomach causes mainly a flow of alkaline juice from the prepyloric glands; this juice consists mostly of mucus and is low in peptic power. Few if any acid-secreting glands are located in the prepyloric portion of the stomach. Likewise the number of these glands is greatly reduced in the cardia and somewhat
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decreased along the angle·· of the stomach on the lesser curvature. The sympathetic fibers presumably inhibit gastric motility but are motor to the pylorus. PATHOLOGIC PHYSIOLOGY
As mentioned previously, hyperacidity is considered to be a constant forerunner of duodenal ulcer. Commonly, hyperacidity is manifested in degree of acidity, as estimated after a test meal, as well as in total amount of acid secreted in twenty-four hours. The cause of increased acidity is not fully known. Neurogenic stimuli may play a large part but likewise chemical factors, faulty neutralization and deficient regulatory mechanisms of gastric secretion may be significant. Thus, with the occurrence of gastric hypersecretion more gastric contents of a lower pH must be neutralized by the duodenum if the acidity of the duodenal contents is to be maintained at a normal value. This is not accomplished in cases of duodenal ulcer. Kearney has demonstrated that in the presence of duodenal ulcer the pH of the duodenal contents is, approximately reversed from that which exists in the normal individual; namely, that 80 per cent of the time, when ulcer is present, the pH of the duodenal contents is below 4.0, the concentration at which free acid appears. When gastric contents enter the duodenum under these circumstances the pH drops well below 4.0 and, instead of returning promptly to a value of 4.0 or higher, it is slow in reaching this value. As a result, increased acidity of duodenal contents occurs which predisposes to the development of an ulcer and militates against its healing once it is present. Medical measures normally are directed toward reducing this duodenal acidity, and such treatment may be sufficiently effective to result in healing. If, however, these measures are discontinued and the same factors are present which initially caused the augmented acidity, ulceration may occur. Certain surgical procedures may decrease the acidity of the duodenal contents by a mechanical and, .therefore, more lasting method; however, simultaneous increase in acidity of the jejunal contents usually occurs if gastrojejunal anastomosis is established and secretion of free acid persists in the stomach. Motor function of the stomach may become altered slightly or markedly when a duodenal ulcer develops. Increased tone in the prepyloric portion of the stomach is a common roentgenologic observation and increased muscular irritability is a frequent occurrence. Delayed emptying of the stomach may be caused by inflammatory reaction in the region of the lesion or by actual sclerotic obstruction of the duodenum. It is remarkable at times how the gastric musculature will respond to an increased demand on its efforts and will continue to empty the stomach adequately despite definite duodenal narrowing. Varying degrees of obstruction may exist without symp-
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tomatic evidence and may be detected only by roentgenologic means or by use of a test meal for motor function. Failure of the stomach to empty properly may be intermittent. The chronically obstructed stomach often becomes large and the surgeon, in planning any operation, should anticipate its return to normal size after relief of obstruction. INDICATIONS FOR SURGICAL TREATMENT
It is generally agreed that medical treatment should be instituted in all cases of duodenal ulcer except those in which certain complications are present. Our experience at the Mayo Clinic indicates that approximately 85 per cent of all patients with this condition can be treated medically. Complications which are considered to indicate the desirability of surgical b'eatment, and which will be discussed only brieHy, may be listed as primary or secondary. In the former group are included hemorrhage, obstruction; perforation, failure of medical management and any doubt as to the benignity of the lesion. Hemorrhage may present itself either in the form of active, acute, massive hemorrhage or as a history of recurrent hemorrhages without active bleeding at. the time the patient is examined. Opinion differs as to the type of treatment advisable for acute massive hemorrhage. In the past treatment was always conservative but in recent years some surgeons have favored emergency surgical treatment. In general it may be stated that the majority of patients who have massive hemorrhage from duodenal ulcer and are less than forty-five years of age respond favorably to medical manllgement. On the contrary, the risk of medical management is increased definitely in the group of patients who are more than forty-five years of age. At present it is our practice to institute medical treatment in all· cases in which massive bleeding from duodenal ulcer occurs. If, after medical treatment has been continued for forty-eight hours, there is still evidence of continued or recurrent bleeding, it is our opinion that immediate surgical intervention is desirable. In other words, the patient is given an opportunity to respond to medical treatment, but if the response is not favorable in forty-eight hours we believe that there should be no further delay in surgical treatment. For the patient who has had several episodes of bleeding one is always a little more inclined to suggest surgical treatment. This is especially true if bleeding occurs under. ordinary circumstances, when the patient has been taking at least fairly good care of himself. Medical treatment which failed to prevent hemorrhages in the past hardly can be considered adequate to prevent hemorrhage in the future. Obstructive lesions caused by duodenal ulcer may be either inHammatory or sclerotic in nature. The inHammatory type of obstructive lesion usually is seen during a subacute exacerbation of symptoms,
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Under proper medical treatment, symptoms of obstruction generally disappear in a week or ten days. It is doubtful, however, whether more than one or two such episodes should be treated medically because they are likely to recur and cause sclerotic narrowing of the duodenum. When a definite cicatricial type of obstructive lesion results, the problem becomes largely mechanical in nature; then there is little to offer but surgical treatment. Perforation by a duodenal ulcer may be either a subacute or an acute process. All agree that acute perforation of a duodenal ulcer constitutes a surgical emergency. The subacute perforating duodenal ulcer generally is one of pronounced activity, causing varying degrees of penetration through the wall of the duodenum. In the advanced case the entire thickness of the duodenal wall has been eroded and the base of the crater consists of adjacent tissue, usually pancreas. When an ulcer of such pronounced activity is present it is unlikely that medical management will result in satisfactory cure. Failure of medical management to relieve symptoms of ulcer long has constituted an indication for surgical treatment. Care must be exercised, however, in determining just when failure of medical management has occurred. One should be confident that an adequate regimen has been followed. Occasionally uncertainty will exist regarding the exact diagnosis in a case of duodenal ulcer. This occurs most often when the lesion is situated at the pylorus and the roentgenologist is unable to say whether it is actually in the duodenum or on the gastric side of the pylorus. A small carcinoma in this vicinity may closely simulate a duodenal ulcer. If any doubt exists as to the benignity of the lesion, surgical exploration should be advised. Thus, if an obstructing lesion at the outlet of the stomach is thought to be a duodenal ulcer, but if the gastric acidity is low and perhaps free hydrochloric acid is absent, exploration should be performed. Besides these primary indications for surgical treatment of duodenal ulcer, there are certain factors of secondary importance, the presence of which tends to favor surgical intervention. These include: a very unfavorable economic status, which virtually prevents the patient from making adequate trial of medical management; the unco-operative nature of a given patient whereby the dietary regimen is not followed; excessive gastric acidity with a value of free hydrochloric acid possibly of 80 or more (Topfer's method); a history of duration for many years and symptoms of marked severity. While no one of these secondary factors alone should be considered to constitute a definite indication for operation, when two or more of them exist in the same case, thought should be given to the advisability of operation.
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GASTRO-ENTEROSTOMY
Physiologic Considerations.-Complete diversion of the gastric contents from the duodenum by a satisfactorily functioning gastroenteric stoma results in marked change in the pH of the duodenal contents. Under these circumstances the duodenal contents constantly are neutral or alkaline and, therefore, the duodenal ulcer heals in virtually every case. Unfortunately, however, the amount of gastric secretion is not reduced by this operation; only the site at which it enters the intestine is changed from the duodenum to the jejunum. The beneficial factor, from the viewpoint of neutralization or dilution of the gastric contents, is that most of the duodenal juices pass either into the stomach or directly along the jejunum where it is joined to the stomach, provided a short jejunal loop has been used in making the anastomosis. Undoubtedly this behavior of duodenal juices COnstitutes a factor of importance in the prevention of jejunal ulceration. When an ulcer develops after gastro-enterostomy it almost always occurs in the distal loop of jejunum in proximity to the stomach. At this site probably the greatest trauma from gastric emptying and the highest acidity occur. In addition to changing the acidity of the duodenal and jejunal contents gastro-enterostomy alters the motor function of the stomach in that it permits satisfactory emptying of the stomach despite obstruction in the first portion of the duodenum. Thus existing duodenal obstruction is eliminated as a factor of significance. Indications.-Although one hears many words of condemnation for gastro-enterostomy, it cannot be denied that many patients have experienced an eminently satisfactory result after this operation. It seems that this fact should be kept in mind because, if this operation is performed with proper indication and its technical execution is correct, good results still may be expected in a large majority of cases True, the possibility of occurrence of jejunal ulcer always remains, but that possibility also exists, to a less extent, after gastric resection. It should be remembered that, in the hands of the average surgeon, gastro-enterostomy entails a definitely lower operative risk than does gastric resection. Castro-enterostomy may be performed as an operation of choice or at times as one of expediency. The patient who qualifies in the former category would be, as a rule, of advanced years; would constitute a poor surgical risk; would have a chronic lesion of long standing, perhaps causing obstruction because of sclerotic changes; would have relatively low gastric acidity; would present a single lesion and no appreciqble associated gastritis and would exhibit a minimal neurogenic factor. At times gastrojejunostomy may be employed in the absence of many of the conditions just mentioned if the technical aspects of gastric resection involve too great difficulty or hazard.
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JAMES T. PRIESTLEY
Such may be the case in dealing with an ulcer deeply placed in a shortened duodenum which permits neither removal of the ulcer and satisfactory closure of the duodenal. stump without jeopardizing the common bile duct nor section of the duodenum immediately distal to the pylorus and satisfactory closure of the duodenal stump. This type of lesion in an obese individual with a small, high-lying stomach and deeply placed duodenum, makes resection more difficult and hazardous and, therefore, may make advisable something less desirable than the surgical procedure of theoretic choice. As the surgeon's experience increases, technical considerations of this type become less of a factor in his choice of operative procedure. Technical Considerations.-The many technical details involved in the establishment of a gastro-enteric stoma will not be discussed, but only a few points will be mentioned which seem of particular importance for the satisfactory postoperative function of gastrojejunal anastomosis. Likewise, only one type of gastrojejunostomy will be considered. The placing of the stoma is important. It should be neither too proximal nor too distal in the stomach; neither should it be too high nor too smalL While there is more than one way of making a gastrojejunal stoma that will permit satisfactory gastric motor function, the preferred type is as follows: The stoma is placed on the posterior wall of the stomach and is extended almost from the lesser curvature down to the greater curvature in' a line ru~ming approximately from the patient's right shoulder to his left foot, with the proximal jejunal loop fixed to the lesser curvature of the stomach and the distal loop joined to the greater curvature. The point at which the distal jejunal loop. is attached to the greater curvature of the stomach should be directly below the angle of the lesser curvature. One should remember that an enlarged, obstructed stomach will decrease in size after relief of the obstruction with corresponding decrease in size of the gastro-enteric stoma. Two or three rows of sutures may be used. Fine suture material is preferred. The stoma in the jejunum should be placed directly opposite the mesenteric border. Less than 0.5 cm. of stomach or jejunum should be inverted into the gastro-enteric lumen, particularly at the point at which the distal loop of jejunum leaves the stomach. The retrocolic type of anastomosis is preferred. The transverse mesocolon should be sutured to the gastric wall at least 2 cm. removed from the site of anastomosis around the entire stoma. The surgeon must be certain that these sutures actually are placed in the gastric wall in the region of the greater curvature and not in the gastrocolic omentum. This requires that several sutures be passed through the gastrocolic omentum and into the anterior gastric wall at the lower angle of the anastomosis. A short proximal jejunal loop should be used.
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one just short enough, perhaps 8 to 10 cm. in length, to permit approximation of the jejunum to the lesser curvature of the stomach without tension, yet without appreciable redundancy. At the conclusion of the operation the distal loop of jejunum should be placed so that it lies to the patient's left in the region of the root of its mesentery. GASTRIC RESECTION
Physiologic Considerations.-The primary purpose of all types of gastric resection performed for duodenal ulcer is to eliminate the factor of acidity in the genesis of ulcer by removal of a major portion of the acid-secreting gastric mucosa. This involves simultaneous eradication of most of the gastric ferments and of a large part (two thirds to four fifths) of the stomach, with resultant decrease in capacity of the stomach as well as decrease in the gastTic phase of digestion. Obviously S4ch an operation entails greater physiologic and anatomic change than is ideal. The small residual gastric capacity which results is responsible occasionally for undesirable postoperative symptoms. The emptying time of the stomach is decreased, which may cause symptoms, and food is permitted to enter the small intestine, duodenum or jejunum, as the case may be, without the normal amount of preliminary change. If gastrojejunal anastomosis. is established, as is the common practice, the amount of the digestive juices which normally are secreted and excreted into the duodenum may be decreased, as has been suggested by Wangensteen and studied by Kolouch. AfteT restoration of gastro-intestinal continuity by gastrojejunal anastomosis the pH of the duodenal contents remains neutral or alkaline and the duodenal ulcer heals in all cases if, for any reason, it is not removed; however, the ulcer almost always is removed at the time of resection. The subsequent danger then, as with gastroenterostomy, is the possibility of jejunal ulceration. This, of course, occurs infrequently if the amount of stomach removed is adequate to eliminate free hydTochloric acid from the gastric contents. The most physiologic type of resection, and the one which I prefer and use whenever feasible, is the Billroth I type. In this procedure the stomach is rejoined to the duodenum after gastric resection. Physiologically this procedure is sounder than certain others in that it permits food to pass from the stomach to the duodenum as it normally does, although the food is not prepared as completely before entering the duodenum as it was prior to operation. One may anticipate, however, virtually normal stimulation of pancreatic and biliary secretory activity. Obviously a jejunal ulcer cannot occur at the site of anastomosis; should ulcer occur in the duodenum the patient is no worse off than he was prior to operation. Resection, wth anastomosis
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of this type, is simpler to perform and entails fewer suture lines than a Billroth II type of operation. Likewise motor function is uniformly satisfactory and the so-called dumping syndrome does not occur. The pH of the duodenal contents is elevated because of reduction in the gastric secretory surface and, consequently, recurrent duodenal ulcera. tion is unlikely. Indications.-Indications for gastric resection will vary with one's current opinion regarding the indications for vagotomy. My view regarding vagotomy is conservative at the present time, for reasons that will appear later. Until vagotomy has had time to prove itself, therefore, gastric resection probably should be used in approximately five out of six cases of duodenal ulcer, at least in the type of cases seen in my experience. It is apparent from previous remarks that resection is not considered an ideal procedure for treatment of duodenal ulcer and it is possible that as time passes this procedure may be supplanted gradually by one or more forms of medical or surgical treatment. At present the ideal patient for gastric resection would be a man of middle age, in good general condition, who had failed to obtain relief despite careful and prolonged adherence to a medical regimen, whose gastric acidity was high, who perhaps had experienced recurrent hemorrhages and who had an active lesion for which resection would not be unduly difficult or hazardous. The presence of multiple ulcers and associated gastritis, as well as of a large neurogenic element, would favor resection rather than conservative operation; however, none of these factors makes for a favorable postoperative result. Technical Considerations.-As mentioned previously, the Billroth I type of anastomosis is preferred to the Billroth II. More specifically, preference is for the Shoemaker modification of the Billroth I type, in which resection of the stomach is carried higher along the lesser curvature than the greater curvature and the end of the stomach, after closure of the lesser curvature to the desired point, is anastomosed directly with the end of the duodenum. To accomplish this operation one must have an adequate amount of duodenum distal to the ulcer that can be mobilized with a good blood supply. Anastomosis must be accomplished without tension and without limitation of resection of the desired amount of stomach. The end of the gastric stump is so formed by appropriate closure of the lesser curvature, that its size corresponds with that of the duodenum. The amount of stomach and duodenum inserted into the gastroduodenal stoma should be small in order that an adequate gastric outlet may be maintained. Although crushing clamps may be used, my preference is for the so-called open anastomosis performed by the use of rubber-covered Doyen forceps. In a Billroth II type of resection it has been well demonstrated that short-loop, retrocolic .anastomosis is followed by results superior to
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those obtained when· long-loop, antecolic anastomosis is employed, although some surgeons advocate the latter type. This latter type, which is technically easier to perform, at times may be used for expediency if the patient is fat, the transverse colon short and thick and the stomach is small and in a high position. Entero-anastomosis between the jejunal loops is unnecessary and undesirable. One may anastomose the entire end of the stomach with the jejunum, or only a part of it after closure of the portion bordering the lesser curvature, according to the method of Hofmeister; the latter procedure is the favored one. None of the prepyloric portion of the stomach should be permitted to remain. Removal of the duodenal ulcer itself is unnecessary, although some state otherwise, so long as satisfactory closure of the duodenal stump is obtained. In practice the ulcer is removed almost invariably. Satisfactory closure of the duodenal stump is most important. Likewise it is essential that there be no angulation or other factor which might interfere with free emptying of the proximal jejunal loop, as increased intraluminal duodenal pressure predisposes to leakage from the duodenal stump. The same technical points discussed in connection with gastro-enterostomy apply in establishing gastrojejunal anastomosis after gastric resection; namely, approximation of the jejunum and the stomach, direction of jejunal loops, length of proximal jejunal loop, suturing the transverse mesocolon well back from the anastomosis and so forth. VAGOTOMY
Physiologic Aspects.-Complete section of the vagus nerves abolishes the psychic phase of gastric secretion and other neurogenic influences on the gastric mucosa. As a result the amount of gastric secretion (gastric enzymes as well as acid) and degree of acidity of the gastric juice are decreased. Usually vagotomy does not result in anacidity or complete absence of free hydrochloric acid, because the activity of the gastric and intestinal phases of gastric secretion persist. Nevertheless, reduction in amount of gastric secretion and in degree of acidity is definite. Lester Dragstedt, who has been largely responsible for the present-day clinical use of bilateral vagotomy in the treatment of duodenal ulcer, emphasizes the marked reduction in night secretion which occurs after this operation. Simultaneously there is a decrease in the motor function of the stomach. This may be manifest clinically, provided gastro-enterostomy is not performed simultaneously, by gastric retention in certain cases in which there were no symptoms of retention preoperatively; in fact, even in some cases in which a gastrojejunal stoma is established temporary gastric retention may occur. What the ultimate (five to fifteen years) results will be on the human stomach from a secretory point of view, as well as
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from that of motor function, is not known and this fact, in my opinion, constitutes one of the chief reasons why bilateral vagotomy should not be performed in a widespread manner at present. For example, it takes some few years, as a rule, for Hirschsprung's disease to cause pronounced enlargement of the colon. In a certain percentage of dogs subjected to bilateral transthoracic vagotomy there has been a return of gastric acidity to its preoperative value five years after operation and, in addition, some of the animals have had a greatly dilated, atonic stomach at that postoperative date. The early (two to three years) postoperative results in human beings apparently have been satisfactory in numerous cases; however, in some cases they have not been good. The vagus nerves do not supply sensory fibers to the stomach, as is evidenced by the fact that intra gastric distention after bilateral vagotomy causes distress. The importance of vagal stimuli to the motor function of the remaining portion of the intestinal tract is not completely understood. From the standpoint of immediate clinical results, vagal stimuli do not appear to be too important. Likewise the significance of vagal stimuli to the secretory and excretory functions of the accessory glands of digestion is not completely known but apparently· such stimuli are not essential, according to impressions gained from observations in early postoperative clinical cases. Indications.-At present probably no two gastric surgeons would offer an identical group of indications for vagotomy in the treatment of duodenal ulcer. One's selection of patients for vagotomy depends, as mentioned previously, on the degree of one's current acceptance of .this procedure for use routinely in the surgical management of duodenal ulcer. As mentioned previously, my opinion is conservative, as I believe that this operation, although promising, should prove itself over a period of five to ten years before it is permitted to replace old and tried methods which, it is known, will give good results in a high percentage of cases. The work of Dragstedt is outstanding; I believe that the operation should be proved in hands such as his rather than by a large number of isolated surgeons over the country, who, of necessity, will have fewer and less well-controlled cases. With this preamble it is apparent that at this time I can present only my personal viewpoint regarding the indications for vagotomy and that these views should not be misinterpreted as facts. In general, 1 have considered the operation indicated if there is nothing else to offer the patient which can give a high assurance of a good result. Thus, in the case of a man twenty years of age, perhaps of Jewish extra<;tion, who is extremely nervous and who suffers from excessive gastric acidity and long-standing symptoms so severe that almost constant hospitalization is required, bilateral vagotomy may be a proper procedure. It is known that in this type of case gastric resec-
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tion, even though extensive, may be followed by formation of jejunal ulcer. In general, then, I believe that at this time the operation should be reserved for the exceptional type of patient who has duodenal ulcer. In contrast, indications for vagotomy in the treatment of jejunal ulcer are perhaps wider; however, this is not the type of lesion under discussion. Gastric retention may occur after transthoracic vagotomy performed for duodenal ulcer, even though preoperatively there was no indication of gastric obstruction as shown by clinical or laboratory investigation. Such retention may be severe enough to require gastroenterostomy. Because of this fact transthoracic vagotomy seldom seems indicated in the treatment of duodenal ulcer. If this viewpoint is accepted, transabdominal vagotomy performed in association with gastro-enterostomy would constitute the alternative and more desirable procedure. Evaluation of late results of this method of treatment will require the lapse of a number of years. The abdominal approach presents the advantage of permitting direct examination of the lesion and exploration of the entire abdomen. It has the disadvantage, until the surgeon has gained considerable experience, of making complete resection of all branches of the vagus nerves somewhat less certain. Technical Aspects.-A prerequisite to the performance of vagotomy is accurate knowledge of the anatomic location and distribution of the fibers of the vagus nerves, both above and below the diaphragm. Failure to section all fibers of these nerves can lead only to confusion and unsatisfactory results. If a transthoracic approach is employed, resection of a generous portion of the left eighth rib affords fine exposure.· Occurrence of a pathologic process previously in the left side of the thorax adds to the difficulties and, in certain cases, may make a right-sided approach more desirable. A generous portion (preferably 3 cm. at least) of each vagus nerve should be resected and an effort made to prevent realignment of the nerve ends, should regeneration occur. In the abdominal approach a left-sided incision, although it is not. essential, aids in obtaining good exposure of the esophagus. Several inches of esophagus should be cleared and extreme care exercised to perform wide resection of all branches of the vagus nerves. A soft rubber catheter, or a strip of gauze on which caudal traction is made after it is looped around the esophagogastric junction, is helpful in obtaining adequate mobilization and exposure of the esophagus. Mobilization adequate to permit rotation of the esophagus in an arc of at least 180 degrees is essential. All. tissue removed should be examined microscopically to aid in the thoroughness of the operation and in the ready recognition of the fibers of the vagus nerves.
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REFERENCES 1. Dragstedt, L. R. and Owens, F. M., Jr.: Supra-diaphragmatic section of the vagus nerves in treatment of duodenal ulcer. Proc. Soc. Exper. BioI. & Med. 53:152-154 (June) 1943. 2. Dragstedt, L. R. and Schafer, P. W.: Removal of the vagus innervation of the stomach in gastroduodenal ulcer. Surgery. 17:742-749 (May) 1945. 3. Gray, J. S., Wieczorowski, E. and Ivy, A. C.: Inhibition of gastric secretion in man with urogastrone. Am. J. Digest. Dis. 7:513-515 (Dec.) 1940. 4. Ivy, A. C. and Gray, J. S.: Enterogastrone. In: Cold Spring Harbor; symposia on quantitative biology. Cold Spring Harbor, Long Island, New York, The Biological Laboratory, 1937, vol. 5, pp. 405-409. 5. Kearney, R. W.: Studies of the duodenal pH in normal subjects and in patients with duodenal ulcer. Thesis, Graduate School, University of Minnesota, 1940, 83 pp. 6. Kolouch, F., Jr.: Rationale for employment of short afferent loop in gastric resection for peptic ulcer. Thesis, Graduate School, University of Minnesota, 1946. 7. Mann, F. C. and Williamson, C. S.: The experimental production of peptic ulcer. Ann. Surg. 77:409-422 (Apr.) 1923.