GASTRIC SURGERY M.D.
Attending Physician, House of Good Shepherd; Associate in Medicine, Kings County HospitaI BROOKLYN, NEW YORK
of the Iiterature reveaIs no mention of stoma strain foIIowing gastric surgery. Ptosis of the abdomina1 viscera has been discussed at Iength, but not in association with the various operations performed for uIcer or carcinoma. In the three cases which are presented, the main compIaints were pain, weakness, and the inability to vomiting, fatigue, carry on work, especiaIIy when the patient was standing for any Iength of time. These patients were taI1, thin and Iong-waisted, with reIaxed abdomina1 waIIs. AI1 three were operated on for peptic uIcer, Case II having been operated upon twice, but the weakness, fatigue and uIcer syndrome persisted. The recurrence of the uIcer syndrome was aided by the indiscretions of the patients, a11 of whom used tobacco and aIcoho1 in more than moderate quantities. The pain, vomiting and heartburn of the uIcer syndrome cIeared up with rest, aIkaIis, diet and sedation, but the weakness and fatigue persisted. The fact that the operations had been performed by exceIIent surgeons kd me to consider other factors which wouId give reIief to these patients. A consideration of the supports of the stomach reveaIs that the fixed supports of this organ are at the esophagus and the pyIorus. The other supports are peritonea1 attachments forming so-caIIed Iigaments aIong the Iesser curvature (the gastrohepatic) and the greater curvature (the gastrocoIic and the gastrospIenic). However, between the esophagus and the pyIorus the stomach is simpIy a ffexible, movabIe bag. In gastric surgery, the stomach is sutured most often to the jejunum, another Aexible, movabIe organ. REVIEW
Try as the surgeon may, he cannot support the stoma resuIting from the operation as the stoma at the pyIorus and esophagus are supported. Hence, there is a downward puII by the smaII intestines and the transverse coIon which causes added strain on the stoma. To this factor, add the Iong-waisted, thin, reIaxed abdominaI waI1 which predisposes to ptosis of the abdomina1 viscera, and the strain on the surgica1 stoma is undoubtedly increased. In the folIowing cases, reIief has been afforded the patients by the use of a hypogastric supporter, a pad with the convex surface pressing against the Iower abdomen, giving support to the abdomina1 viscera and thereby Iessening the strain on the stoma. The reIief from strain may aIso improve the circuIation about the stoma, and this wouId be a factor in preventing the occurrence of margina uIcer. CASE I. W. McK., age 67, an eIectrician, was first seen on March 31, 1936. He had been operated upon at St. Luke’s HospitaI in New York City about fifteen years previousIy for stomach uIcers. X-ray reveaIed a partiaI gastrectomy. The patient complained of weakness and fatigue after working a few hours on his feet. He had nausea and vomiting on taking soIid food onIy, and suffered from epigastric pain, reIieved by miIk and aIkaIies. Heartburn and Ioss of weight were further symptoms. This man was a heavy user of aIcoho1 and tobacco. Beyond the stomach compIaint he had aIways been well. He was a taI1, long-waisted individua1 with a thin, reIaxed abdomina1 waI1. His appearance w& paIe and drawn, he was bent over, and spoke as though extremeIy tired. The heart tones were duI1 and there was sinus rhythm. The bIood pressure was 150/8o, puIse 80,
NEW SERIES VOL. XLIV,
hemogIobin 70 per cent (TaIIquist). CIinicaIIy he appeared arterioscIerotic. EIectrocardiograph findings were myocardial damage, without coronary damage.
the smaI1 intestine with considerabIe puI1 on the stoma, partiaIIy occluding it. When the intestinal Ioops were filled, the pain and nausea began. Medication gave no reiief.
FIG. I. Abdominal At this time, the diagnosis was one of myocardia1 damage, with peptic uIcer (marginal), and malnutrition. X-ray reveaIed an uIcer at the stoma, with no obstruction present. Treatment consisted of twenty-four injections of Iarostidin, modified sippy diet, and aIkaIi therapy. Within three weeks the pain, nausea and heartburn had subsided. However, the weakness and the fatigue persisted and no gain in weight occurred. The marked ptosis of the smaI1 and large bowel was considered to be causing the Iatter symptoms. Hypogastric support was given, with the resuIt that within two months there was a gradua1 subsidence of the fatigue and weakness, together with a gain in 1937 there weight of 20 pounds. In January was a slight recurrence of the uIcer syndrome foIIowing excessive beer drinking but there was no recurrence of the weakness and fatigue. CASE II. D. O’C., age 38(?), a poIiceman, was examined October 22, 1933. He had had a simple gastroenterostomy done at the Lenox Hi11 HospitaI (New York) and a gastric resection at the Mayo CIinic. He compIained chiefly of weakness and fatigue after a few hours in the erect position, epigastric pain, and vomiting (solids or Iiquids), except when in the prone position. He was a habitua1 smoker and drank much beer. This patient was aIso of the taI1, Iong-waisted type, with thin, reIaxed abdomina1 waI1. There was no pathology evident on thorough examination. FIuoroscopv reveaIed marked Dtosis of __
American Journal of Surgery
Hypogastric support was given, which gave him reIief from the pain and vomiting. In two months he gained 20 pounds, and the weakness and fatigue graduaIIy disappeared. OccasionaIIy he suffers acute epigastric distress because of his refusa1 to give up beer. C&E III. L. C., age 36, had had a simpIe gastroentorostomy done at Jefferson HospitaI in 1925. This patient compIained chiefly of occasiona epigastric pain, weakness and fatigue after a few hours of standing on his feet, and occasiona heartburn. Heavy use of tobacco and moderate use of aIcoho1 were noted. The patient was taI1, with thin, reIaxed abdomina1 waI1, Iong-waisted in type. X-ray was negative for uIcer. The weakness, fatigue and the inability to gain weight were the principal complaints. Treatment consisted of appIication of a hypogastric supporter. In six weeks there was a marked diminution in the weakness and the fatigue, together with a gain of 8 pounds. The resuIts obtained in the above cases justify a consideration of this apphance in the postoperative care of gastric surgery cases for the body type mentioned. The appliance is simply a metal pad with a convex surface covered with chamois and heId in place with two fIexibIe stee1 bands covered with Ieather and easiIy adjusted in the sacroiliac region. The beIt is applied
AmericanJournal of Surgery
in the prone position sIightIy eIevated.
SUMMARY I. Stoma strain is evidenced by weakness, fatigue and the inabiIity to gain weight. 2. The stomas in these cases were functioning, except in Case II where the puI1 on the fuI1 jejunum partially occIuded the stoma.
3. Most chronic uicer patients are Iongwaisted and present a thin abdomina1 muscuIature. 4, Hypogastric support of the ptosed abdomina1 viscera relieved the symptoms of stoma strain. REFERENCES MERLO, GIOVANNO. Policlinico, 43: BORTZ. Am. J. M. SC., r80: 59-71,
314 (July 15) 1936. 1930. BORTZ.J. A. M.:A., 93: 17-20, 1929.
THE canal of Nuck in the femaIe corresponds in the maIe and may be the source of herniation type of hernia.
to the processus vaginahs of the oblique (indirect)