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Surgery for peptic ulcer in patients with chronic lung disease
Surgery for Peptic Ulcer in Patients with Chronic Lung Disease ARTHUR J. OKINAKA,
M.D.,
From the Defiartment of Surgery, The New York HospitulCornell Medical Center, New York, New York. ITH the increasing prevalence
of chronic and pulmonary emphysema, the surgeon can expect to see a larger and larger number of patients with pulmonary insufficiency who require operation, Various authors [l-7] have stated that peptic ulcer disease is far more common in these patients with chronic lung disease than in the general population; some comment that the ulcer diathesis is also more severe. This report considers the relationship of peptic ulcer and chronic lung disease and discusses certain aspects of the management of these patients with impaired pulmonary function who require upper abdominal operations. Since neither peptic ulcer nor chronic lung disease is fully understood, there are many questions about the association of these conditions. In practical experience these patients with serious pulmonary disease and a complicated peptic ulcer present a difficult problem and require considerable attention. This paper contains a case report of a patient recently seen at The New York Hospital-Cornell Medical Center and a summary of cases of other patients with chronic bronchitis and pulmonary emphysema who were operated upon for peptic ulcer. CASE REPORT
The patient, a sixty-eight year old white man, was admitted to The New York Hospital-Cornell Medical Center for the third time in November 1965 with complaints of weakness and tarry stools. In 1963 he was first admitted for chronic bronchitis, pulmonary emphysema, and car pulmonale. Routine arterial blood samples in 1963 had a pH of 7.35, a partial 1967
York, New
York
pressure of carbon dioxide of 70 mm. Hg, and a partial pressure of oxygen which corresponded to 90 per cent saturation. In 1964 he was again admitted for pulmonary complaints; an upper gastrointestinal series performed at this time was interpreted as showing an irritable duodenal bulb but no ulcer crater. The partial pressure of carbon dioxide in arterial blood was 61 mm. Hg. On this last admission in 1965, the patient gave a history of vague epigastric distress for thirteen years. Six days prior to admission he had noticed tarry stools and weakness. On admission hematocrit was 22 per cent and soon thereafter the rapid administration of 20 units of whole blood was required to maintain his blood pressure. At operation chronic ulcer measuring 1.5 by 1 cm. was found low in the second portion of the duodenum, penetrating medially in the head of the pancreas. A subtotal gastric resection was performed, closing the duodenum proximal to the ulcer and leaving the ulcer undisturbed; the proximal jejunum was connected to the gastric remnant by a Polya type of anastomosis. Gastrostomy and tracheostomy were also performed. After operation the partial pressure of carbon dioxide in the arterial blood was 100 mm. Hg and the patient was managed with a volume-cycled respirator. By the fifteenth postoperative day the partial pressure of carbon dioxide was 40 mm. Hg; the patient was breathing unassisted and appeared to be progressing well. On the thirtieth postoperative day he became hypotensive and passed tarry stools. He was again explored using general anesthesia and a large marginal ulcer measuring 5 by 8.5 cm. was found; the gastric remnant was grossly normal in appearance. The stomach was resected higher and the vagus nerves were divided. The microscopic sections of the stomach were unremarkable. The following day, the partial pressure of carbon dioxide was 44 mm. Hg, the nasogastric tube drained only small amounts of old blood, and the patient generally appeared to be doing well. On the second day he suddenly had massive bleeding again and died. On postmortem examination the lungs showed severe changes of chronic bronchitis and
W bronchitis
Vol. 113, Apvil
New
545
Okinaka TABLE SUMMARY
OF FOURTEEN
PATIENTS ULCERS
Patients
V’ITH
CHRONIC
OF STOMACH
LUNG
OR DUODENUM
Age (yr.) and Sex
Location of Ulcer
Indication for Operation
1 2
58, M 58, M
Stomach Duodenum
? Diagnosis Obstruction
3
61, M
Stomach
Bleeding
4
62,M
Stomach
Bleeding
5 6
64, F 66, M
Duodenum Duodenum
Bleeding Bleeding
7
67, M
Stomach
? Diagnosis
8 9
68, M 69, M
Stomach Stomach
Bleeding Bleeding
10
69, M
Duodenum
Obstruction
11 12 13
70, M 72, F 78, M
Stomach Stomach Stomach
Bleeding Bleeding ? Diagnosis
14
78, M
Stomach
? Diagnosis
OF
OTHER
WHO DURING
HAD
SUBTOTAL
A TEN
YEAR
GASTRIC
RESECTION
FOR BENIGN
PERIOD
Comments Alive and well after 4 yr. Postoperatively atelectasis developed requiring bronchoscopy; patient alive after 5 yr. Perforated gastric ulcer was plicated 8 days before; gastrointestinal bleeding required gastrectomy; tracheostomy performed postoperatively for atelectasis; patient alive after 7 yr. Seen once after operation, then lost to follow-up study; patient was doing well Alive and well for 7 yr. 1 Xrr. later patient had dismantling, resection, and vagotomy for marginal ulcer; alive and well 4 yr. later Alive after 2 yr. with diabetes, osteoarthritis, and vascular disease Alive and well after 5 mo. Prior tracheostomy for pulmonary insufficiency and cardiac arrest; pCOl was 52 mm. Hg preoperatively; cardiac arrest postoperatively; patient died Patient had lobectomy for lung carcinoma 3 mo. later and died 2 mo. after that Postoperative tracheostomy; patient alive after 1 yr. Alive and well after 3 yr. 1 MO. postoperatively patient had bronchopneumonia requiring tracheostomy; he died in hospital Patient did well; died of pulmonary disease after 2.5 yr.
pulmonary emphysema and there was car pulmonale. The liver demonstrated chronic passive congestion. The initial ulcer in the second portion of the duodenum had almost completely healed and no tumor of the pancreas was present. The bleeding had been from acute ulceration in the gastric remnant. SUMMARY
I
DISEASE
CASES
In a ten year period from 1956 through 1965, 689 subtotal gastric resections were performed for benign and malignant disease on the surgical services at The New York Hospital-Cornell Medical Center [8]. Fifty-five of these patients had the diagnosis of chronic bronchitis and pulmonary emphysema at the time of operation. Only thirty-seven of these fifty-five patients had proved benign ulcer disease of the stomach or duodenum. The pulmonary disease was of varying degrees of severity in the thirtyseven patients; fourteen of them had positive findings for chronic lung disease by history, physical examination, and chest roentgenogram. (Table I.) Thus, for purposes of discussion these fourteen patients were considered to have significant pulmonary disease. The average age of the fourteen patients was 67 ( f 3.1) years ; 71 per cent had gastric ulcers
and 57 per cent were operated upon for bleeding. The vital capacity ranged from 48 per cent to 75 per cent of predicted normals. In the remaining twenty-three patients theaverage age was 59 (+8.8) y ears. Fifty-seven per cent of the twenty-three patients had gastric ulcers and 42 per cent were operated upon for bleeding. There were no postoperative pulmonary complications in these twenty-three patients. The charts of patients who underwent gastroenterostomy and vagotomy during this same period were also reviewed. One patient similar to those shown in Table I was found. He was a sixty-seven year old man (previously reported upon [9]) who had gastroenterostomy and vagotomy for a duodenal ulcer. During the operation severe bronchospasm developed and he baas given corticosteroids. He is alive at the time of this writing, three years later. COMMENTS
In the past the relationship of chronic lung disease and peptic ulcer has been examined by collecting groups of patients with chronic bronchitis and pulmonary emphysema defined by certain clinical criteria and then by Amevican
Jouvnal of Surgery
Peptic Ulcer and Chronic Lung Disease tletermining the frequency with which ulcers demonstrated by roentgenographic examination occur. In this way a greater prevalence of peptic ulcers in patients with chronic lung disease has been reported. Believing that a specific relationship exists, investigators suggest various mechanisms by which lung disease can produce peptic ulcer. In practice it is important to know whether peptic ulcers result from pulmonary insufficiency or whether the diseases are simply coincidently associated, since in one case management is based on a judgment of a chronically failing respiratory system which produces the additional problem of a complicated peptic ulcer and in the other, the two processes are viewed as separate entities, one possibly being surgically curable. A group of patients was identified from the surgical services who underwent gastric resection for proved benign ulcers and who had chronic lung disease as an associated condition. While patients may range from those with normal pulmonary function who require gastric resection to those who are believed to have lung disease too severe to allow any consideration of surgery, there were fourteen patients who were believed to have serious pulmonary disease and who had gastric resection performed. The purpose in discussing these and similar cases is to examine the association of peptic ulcer and chronic lung disease and to suggest how a greater number may be offered surgery. The question of the relationship between chronic lung disease and peptic ulcer is an important one. Platts [IO] compared the incidence of peptic ulceration in patients with lung disease with that in patients with other diseases and could not show an increased incidence in patients with chronic lung disease. \Vhile others have also been unable to correlate these two processes satisfactorily, the majority of the reports in the literature affirm a significant association. Many possible mechanisms have been suggested, but most authors expect that the relationship will depend in some way upon carbon dioxide retention which is the characteristic of chronic lung disease and upon gastric acid secretion. Ellison and her associates [2] have reported that gastric acid secretion increases with elevated levels of carbon dioxide demonstrated by the collection of gastric secretion with a nasogastric tube while the subject breathes a 5 per cent Vol. 11.3.
Api
1967
.-Ai
carbon dioxide-!)5 per cent oxygen ga5 mixture for twenty-five minutes by face mask. Zasly, Baum, and Rumba11 [II ] observed no significant increase in acidity after carbon dioxide in halation. Platts [IO] could not find any correlation between the presence of respiratory acidosis and gastric acid secretion by analysis with a gastric tube. A unique opportunity to study this problem was recently provided by an eighty-three year old man admitted to this hospital. The patient had had a partial esophagectomy two vears before at this institution for carcinoma of the esophagus; no roentgen ray therapy teas given. Continuity had been restored by bringing the stomach high into the chest with an esophagogastrostomy. The patient was well until a productive cough developed a fen days prior to admission. At this time sputum was copious and contained bile ; roentgenograms demonstrated a bronchoesophageal fistula and pneumonia. On endoscopic examination a communication 4 mm. in diameter was visualized between the left mainstem bronchus and the site of previous anastomosis. Biopsies revealed no tumor, but cytologic study showed the sputum to be Papanicolaou class v. Otherwise, the patient’s general physical and mental state appeared to be good. Under local anesthesia the stomach was divided below the diaphragm and two gastrostomies were created. He tolerated the procedure well and rapidly improved. The denervated, partially intrathoracic gastric pouch was dependently drained by a tube. (Fig. 1.) The distal gastrostomy drained the duodenum and part of the gastric antrum. Only small amounts of viscid material which contained no acid were collected from the proximal gastrostomy until tube feedings were instituted through the distal gastrostomy about a week after operation. With the tube feedings the volume of gastric secretion from the pouch increased and specimens had a pH of 3.0. The patient tolerated tube feeding in the amount of 300 cc. every ttvo hours beginning at 9 A.M. and ending at :J :I..zI. and he was maintained on this regimen. ‘I’\velve hour collections, S A.M. to 8 P.M., averaged 152.7 (=t8.3) mEq. of total acid over seven consecutive days; the 8 P.M. to S A.M. collections averaged 33.X (* 4.7) mEq. of total acid. The patient was studied a half hour after the second tube feeding at 11 A.M. by the technic diagrammed in Figure 1. He was seated with a
548
Okinaka
SPIROMETER FILLED
WITH
5xco* 95%
0.2
I
CO2
ANALYZER AND
RECORDER
FIG. 1. Diagram of apparatus used to study a patient with a gastric pouch. A record from an actual test is shown; the arrow designates the beginning of the study.
mouthpiece and a nose clip in place and secretions from the gastric pouch were collected for ten minutes while he breathed through a one way circuit. He breathed either room air or a 5 per cent carbon dioxide-95 per cent oxygen gas mixture from a Tissot spirometer which recorded each breath. Expired air was monitored with an infrared carbon dioxide analyzer which was connected to a recorder (an actual record of a study is shown in Figure 1 where the expired air maintains a concentration of 5.0 to 6.5 per cent). Ten minutes was the longest period the patient could breathe into the apparatus comfortably and allowed the collection of about 0.5 mEq. of total acid from the pouch. On repeated examinations by this technic no increase in gastric acid secretion was demonstrated from the pouch with the inhalation of 5 per cent carbon dioxide. If gastric acid secretion is stimulated by elevated tensions of carbon dioxide, these observations suggest that the mechanism is mediated by the vagus nerves. These same observations are, however, also consistent with the hypothesis that increased partial pressures of carbon dioxide have no augmenting effect on gastric acid secretion. It is not possible with our present limited knowledge to be certain which of these suppositions is true. The paucity of cases available for this study was initially disturbing and alternative surgical procedures for the treatment of peptic ulcer were reviewed for the same period of time. Other authors also have had only relatively
small numbers of patients to report. On reviewing our experience there were three interesting aspects to the collected series of cases: (1) the incidence of postoperative pulmonary complications, (2) the age of the patients, and (3) the final outcome. Stein and associates [12] have recently discussed the increased incidence of postoperative pulmonary complications in patients with pre-existing lung disease. The reasons for this, while they are still somewhat obscure, relate in some way to the intrathoracic alterations which occur with upper abdominal operations. There were four postoperative pulmonary complications in the fourteen patients shown in Table I and three of these patients required tracheostomy. The fourteen patients were significantly older (p< 0.01) than the twenty-three patients who were thought to have less serious lung disease and in whom no postoperative pulmonary complications occurred. The two groups however were similar in other respects; both had a majority of ulcers located in the stomach and were operated upon for bleeding. Afflicted with other disease associated with advanced age, the patients noted in Table I died of various causes. One was in critical condition when taken to the operating room and died a short time after operation. Survival, nevertheless, was achieved in many of the patients and good results were obtained. The management of these patients with both chronic lung disease and a complicated peptic ulcer is usually tedious and difficult. OccasionAmerican
Journal of Surgery
Peptic
Ulcer
and
Chronic
ally the ulcer diathesis is severe and the disease, despite all of the provisions made, takes a fatal course as ulcers may in association with other conditions such as liver disease, burns, and sepsis. At times pulmonary insufficiency resulting from chronic bronchitis and pul monary emphysema may be totally refractory to treatment, but usually some improvement can be obtained. This is seen in the case of the sixty-eight year old man; with intensive care the condition of a patient with long-standing pulmonary disease was improved, as demonstrated by partial pressures of 40 mm. Hg of carbon dioxide obtained in this particular patient. In general it is prudent at this time to consider the lung disease and ulcer as separate entities, to treat the peptic ulcer by usual well established principles and to manage the chronic lung disease expectantly by following up the patient closely and by carrying out whatever is indicated. In this situation standard surgical technics should be employed and general anesthesia is preferred. During the time of operation the patient is individually managed by the anesthesiologist who keeps the main airways clear by careful suctioning. manually insures adequate exchange of gases, and maintains high levels of oxygen saturation in the blood with proper mixtures of gases. These patients with respiratory insufficiency can be expected to tolerate the period of the operation. The days immediately after operation are the most difficult and critical. With upper abdominal operations certain structural and functional changes in the lungs are known to occur. These include a decrease in pulmonary compliance, a decrease in lung volumes. a decrease in oxygen saturation, and a change in the pattern of breathing [13,143. While these alterations are usually inconsequential for patients with normal lungs, they become important. in patients with limited pulmonary reserve. Since these changes occur during the days immediately after operation! it is necessary to follow up these patients closely in the early postoperative period. In the past the analysis of arterial blood samples had not been readily available in a general hospital; now, apparatus for the rapid and accurate measurement of blood gases and pH have been developed and these technics are easily employed. The arterial blood in these patients should be monitored. In patients who require tracheostomy, a large-bore, cuff cd
Lung
Disease
tracheostomy tube can be implemented with a small ventilation meter or respirometer described by Wright for measuring tidal air exchange [15,26]. By briefly inflating the cuff on the tracheostomy tube, ventilation can be completely diverted through the ventilation meter which is connected by means of adaptors to the tracheostomy tube; in this way air exchange may be quickly assessed with reason able accuracy. It has been useful to correlate ventilation measured in this fashion with the values of the arterial blood gases and pH drawn at the same time. The values of the arterial blood analysis should be interpreted as serial measurements; carbon dioxide values over 49 mm. Hg may be arbitrarily taken as suggested by Campbell [17] and Scadding [18] as indicating respiratory insufficiency. If the tidal volume falls below 300 cc. usually some form of assisted or controlled respiration is necessary. If ventilatory insufficiency is being treated with a mechanical respirator, the volume of air being delivered to the patient should be known as well as the arterial blood gases and pH while the patient is being ventilated. With the volume-cycled respirators which deliver a specific volume with each stroke, ventilation is determined by a gauge. In other types with pressure and flow-rate gauges, the volume of gas being delivered by the respirator to the patient may be measured by adapting the respirometer or ventilation meter to the expiratory outlet. With the cuff on the trachcostomy tube inflated, the tidal expiratory volume can be observed in this manner. These suggested technics are simple to perform and are convenient ways of monitoring the patient, The necessity of humidification, bronchodilators, frequent suctioning, and high oxygen tensions have been sufficiently m~plxt~izecl in the literature. SUMMARY
Of 689 patients who underwent subtotal gastric resection on the surgical services of The New York Hospital-Cornell Medical Center, there were fourteen patients with significant chronic lung disease who had resection for proved benign ulcers of the stomach or duodenum. These patients were older and as a group showed a high incidence of postoperative pulmonary complications. Survival and good results can be achieved. Patients with chronic lung disease and peptic ulcers
Okinaka are best managed by assuming the two conditions are separate processes and by treating each in accordance with established principles. The results of studies performed on an eightythree year old man with a gastric pouch are also presented. REFERENCES
1. COHEN, A. C. and JENNY, F. S. The frequency of peptic ulcer in patients with chronic pulmonary emphysema. Am. Rev. Resp. Dis., 85: 130, 1962. 2. ELLISON, L. T., ELLISON, R. G., CARTER, C. H., DANIELL, D., JR., and MOORE, V. A., JR. The role of hypercapnia and hypoxia in the etiology of peptic ulceration with chronic obstructive pulmonary emphysema. Am. Rev. Resp. Dis., 89: 909, 1964. 3. GLICK, D. L. and KERN, F., JR. Peptic ulcer and chronic obstructive bronchopulmonary disease. A prospective clinical study of prevalence. Gastroenterology, 47: 153, 1964. 4. LATTS, E. M., CUMMINS,J. E., and ZIEVE, L. Peptic ulcer and pulmonary emphysema. Arch. Int. Med., 97: 576, 1956. 5. XAITOVE, A. and TENNEY, S. M. Effects of hypoxia and hypercapnia on gastric acid secretion in man. Gastroenterology, 43: 181, 1962. 6. SILEN, W., BROWN, W. H., and EISEMAN, B. Peptic ulcer and pulmonary emphysema. Arch. Surg., 78: 897, 1959. 7. WEBER, J, M. and GREGG, L. A. The coincidence of
8.
9.
10.
11.
12.
13.
14. 15. 16.
17. 18.
benign gastric ulcer and chronic pulmonary disease. Finn. Int. Med., 42: 1026, 1955. The Xew York Hospital-Cornell Medical Center Annual Report, Department of Surgery, 1956 to 1965. OKINAKA, A. J. and GLENN, F. The surgical patient with emphysema and CO2 retention. Axh. Surg., 90: 436, 1965. PLATTS, M. M. Peptic ulceration and gastric acid secretion in patients with chronic respiratory acidosis. Gastroenterology, 38: 317, 1960. ‘ZASLY, L., BAUM, G. L., and RUMBALL, J. M. The incidence of peptic ulceration in chronic obstructive pulmonary emphysema. Dis. Chest, 37: 400, 1960. STEIN, M., KOOTA, G. M., SIMON, M., and FRANK, H. A. Pulmonary evaluation of surgical patients, J.A.M.A., 181:765, 1962. LEWIS, F. J. and WELSH, J. A. Respiratory mechanics in postoperative patients. Surg. Gynec. b Obst., 120: 305, 1965. OKINAKA, A. J. Postoperative pattern of breathing and compliance. Arch. Surg., 92: 887, 1966. WRIGHT, B. M. A respiratory anemometer. J. Physiol., 125: 25, 1955. DUNN, J. F. and EZI-ASHI, T. I. The accuracy of the respirometer and Ventigrator. Brit. J. Anesth., 34: 422, 1962. CAMPBELL,E. J. M. Respiratory failure. &it. M. J., 1: 1451, 1965. SCADDING, J. G. Patterns of respiratory insufficiency. Lnncet, 1: 701, 1966.
Amevican
Journal
ofSurgery
M.D.,
From the Defiartment of Surgery, The New York HospitulCornell Medical Center, New York, New York. ITH the increasing prevalence
of chronic and pulmonary emphysema, the surgeon can expect to see a larger and larger number of patients with pulmonary insufficiency who require operation, Various authors [l-7] have stated that peptic ulcer disease is far more common in these patients with chronic lung disease than in the general population; some comment that the ulcer diathesis is also more severe. This report considers the relationship of peptic ulcer and chronic lung disease and discusses certain aspects of the management of these patients with impaired pulmonary function who require upper abdominal operations. Since neither peptic ulcer nor chronic lung disease is fully understood, there are many questions about the association of these conditions. In practical experience these patients with serious pulmonary disease and a complicated peptic ulcer present a difficult problem and require considerable attention. This paper contains a case report of a patient recently seen at The New York Hospital-Cornell Medical Center and a summary of cases of other patients with chronic bronchitis and pulmonary emphysema who were operated upon for peptic ulcer. CASE REPORT
The patient, a sixty-eight year old white man, was admitted to The New York Hospital-Cornell Medical Center for the third time in November 1965 with complaints of weakness and tarry stools. In 1963 he was first admitted for chronic bronchitis, pulmonary emphysema, and car pulmonale. Routine arterial blood samples in 1963 had a pH of 7.35, a partial 1967
York, New
York
pressure of carbon dioxide of 70 mm. Hg, and a partial pressure of oxygen which corresponded to 90 per cent saturation. In 1964 he was again admitted for pulmonary complaints; an upper gastrointestinal series performed at this time was interpreted as showing an irritable duodenal bulb but no ulcer crater. The partial pressure of carbon dioxide in arterial blood was 61 mm. Hg. On this last admission in 1965, the patient gave a history of vague epigastric distress for thirteen years. Six days prior to admission he had noticed tarry stools and weakness. On admission hematocrit was 22 per cent and soon thereafter the rapid administration of 20 units of whole blood was required to maintain his blood pressure. At operation chronic ulcer measuring 1.5 by 1 cm. was found low in the second portion of the duodenum, penetrating medially in the head of the pancreas. A subtotal gastric resection was performed, closing the duodenum proximal to the ulcer and leaving the ulcer undisturbed; the proximal jejunum was connected to the gastric remnant by a Polya type of anastomosis. Gastrostomy and tracheostomy were also performed. After operation the partial pressure of carbon dioxide in the arterial blood was 100 mm. Hg and the patient was managed with a volume-cycled respirator. By the fifteenth postoperative day the partial pressure of carbon dioxide was 40 mm. Hg; the patient was breathing unassisted and appeared to be progressing well. On the thirtieth postoperative day he became hypotensive and passed tarry stools. He was again explored using general anesthesia and a large marginal ulcer measuring 5 by 8.5 cm. was found; the gastric remnant was grossly normal in appearance. The stomach was resected higher and the vagus nerves were divided. The microscopic sections of the stomach were unremarkable. The following day, the partial pressure of carbon dioxide was 44 mm. Hg, the nasogastric tube drained only small amounts of old blood, and the patient generally appeared to be doing well. On the second day he suddenly had massive bleeding again and died. On postmortem examination the lungs showed severe changes of chronic bronchitis and
W bronchitis
Vol. 113, Apvil
New
545
Okinaka TABLE SUMMARY
OF FOURTEEN
PATIENTS ULCERS
Patients
V’ITH
CHRONIC
OF STOMACH
LUNG
OR DUODENUM
Age (yr.) and Sex
Location of Ulcer
Indication for Operation
1 2
58, M 58, M
Stomach Duodenum
? Diagnosis Obstruction
3
61, M
Stomach
Bleeding
4
62,M
Stomach
Bleeding
5 6
64, F 66, M
Duodenum Duodenum
Bleeding Bleeding
7
67, M
Stomach
? Diagnosis
8 9
68, M 69, M
Stomach Stomach
Bleeding Bleeding
10
69, M
Duodenum
Obstruction
11 12 13
70, M 72, F 78, M
Stomach Stomach Stomach
Bleeding Bleeding ? Diagnosis
14
78, M
Stomach
? Diagnosis
OF
OTHER
WHO DURING
HAD
SUBTOTAL
A TEN
YEAR
GASTRIC
RESECTION
FOR BENIGN
PERIOD
Comments Alive and well after 4 yr. Postoperatively atelectasis developed requiring bronchoscopy; patient alive after 5 yr. Perforated gastric ulcer was plicated 8 days before; gastrointestinal bleeding required gastrectomy; tracheostomy performed postoperatively for atelectasis; patient alive after 7 yr. Seen once after operation, then lost to follow-up study; patient was doing well Alive and well for 7 yr. 1 Xrr. later patient had dismantling, resection, and vagotomy for marginal ulcer; alive and well 4 yr. later Alive after 2 yr. with diabetes, osteoarthritis, and vascular disease Alive and well after 5 mo. Prior tracheostomy for pulmonary insufficiency and cardiac arrest; pCOl was 52 mm. Hg preoperatively; cardiac arrest postoperatively; patient died Patient had lobectomy for lung carcinoma 3 mo. later and died 2 mo. after that Postoperative tracheostomy; patient alive after 1 yr. Alive and well after 3 yr. 1 MO. postoperatively patient had bronchopneumonia requiring tracheostomy; he died in hospital Patient did well; died of pulmonary disease after 2.5 yr.
pulmonary emphysema and there was car pulmonale. The liver demonstrated chronic passive congestion. The initial ulcer in the second portion of the duodenum had almost completely healed and no tumor of the pancreas was present. The bleeding had been from acute ulceration in the gastric remnant. SUMMARY
I
DISEASE
CASES
In a ten year period from 1956 through 1965, 689 subtotal gastric resections were performed for benign and malignant disease on the surgical services at The New York Hospital-Cornell Medical Center [8]. Fifty-five of these patients had the diagnosis of chronic bronchitis and pulmonary emphysema at the time of operation. Only thirty-seven of these fifty-five patients had proved benign ulcer disease of the stomach or duodenum. The pulmonary disease was of varying degrees of severity in the thirtyseven patients; fourteen of them had positive findings for chronic lung disease by history, physical examination, and chest roentgenogram. (Table I.) Thus, for purposes of discussion these fourteen patients were considered to have significant pulmonary disease. The average age of the fourteen patients was 67 ( f 3.1) years ; 71 per cent had gastric ulcers
and 57 per cent were operated upon for bleeding. The vital capacity ranged from 48 per cent to 75 per cent of predicted normals. In the remaining twenty-three patients theaverage age was 59 (+8.8) y ears. Fifty-seven per cent of the twenty-three patients had gastric ulcers and 42 per cent were operated upon for bleeding. There were no postoperative pulmonary complications in these twenty-three patients. The charts of patients who underwent gastroenterostomy and vagotomy during this same period were also reviewed. One patient similar to those shown in Table I was found. He was a sixty-seven year old man (previously reported upon [9]) who had gastroenterostomy and vagotomy for a duodenal ulcer. During the operation severe bronchospasm developed and he baas given corticosteroids. He is alive at the time of this writing, three years later. COMMENTS
In the past the relationship of chronic lung disease and peptic ulcer has been examined by collecting groups of patients with chronic bronchitis and pulmonary emphysema defined by certain clinical criteria and then by Amevican
Jouvnal of Surgery
Peptic Ulcer and Chronic Lung Disease tletermining the frequency with which ulcers demonstrated by roentgenographic examination occur. In this way a greater prevalence of peptic ulcers in patients with chronic lung disease has been reported. Believing that a specific relationship exists, investigators suggest various mechanisms by which lung disease can produce peptic ulcer. In practice it is important to know whether peptic ulcers result from pulmonary insufficiency or whether the diseases are simply coincidently associated, since in one case management is based on a judgment of a chronically failing respiratory system which produces the additional problem of a complicated peptic ulcer and in the other, the two processes are viewed as separate entities, one possibly being surgically curable. A group of patients was identified from the surgical services who underwent gastric resection for proved benign ulcers and who had chronic lung disease as an associated condition. While patients may range from those with normal pulmonary function who require gastric resection to those who are believed to have lung disease too severe to allow any consideration of surgery, there were fourteen patients who were believed to have serious pulmonary disease and who had gastric resection performed. The purpose in discussing these and similar cases is to examine the association of peptic ulcer and chronic lung disease and to suggest how a greater number may be offered surgery. The question of the relationship between chronic lung disease and peptic ulcer is an important one. Platts [IO] compared the incidence of peptic ulceration in patients with lung disease with that in patients with other diseases and could not show an increased incidence in patients with chronic lung disease. \Vhile others have also been unable to correlate these two processes satisfactorily, the majority of the reports in the literature affirm a significant association. Many possible mechanisms have been suggested, but most authors expect that the relationship will depend in some way upon carbon dioxide retention which is the characteristic of chronic lung disease and upon gastric acid secretion. Ellison and her associates [2] have reported that gastric acid secretion increases with elevated levels of carbon dioxide demonstrated by the collection of gastric secretion with a nasogastric tube while the subject breathes a 5 per cent Vol. 11.3.
Api
1967
.-Ai
carbon dioxide-!)5 per cent oxygen ga5 mixture for twenty-five minutes by face mask. Zasly, Baum, and Rumba11 [II ] observed no significant increase in acidity after carbon dioxide in halation. Platts [IO] could not find any correlation between the presence of respiratory acidosis and gastric acid secretion by analysis with a gastric tube. A unique opportunity to study this problem was recently provided by an eighty-three year old man admitted to this hospital. The patient had had a partial esophagectomy two vears before at this institution for carcinoma of the esophagus; no roentgen ray therapy teas given. Continuity had been restored by bringing the stomach high into the chest with an esophagogastrostomy. The patient was well until a productive cough developed a fen days prior to admission. At this time sputum was copious and contained bile ; roentgenograms demonstrated a bronchoesophageal fistula and pneumonia. On endoscopic examination a communication 4 mm. in diameter was visualized between the left mainstem bronchus and the site of previous anastomosis. Biopsies revealed no tumor, but cytologic study showed the sputum to be Papanicolaou class v. Otherwise, the patient’s general physical and mental state appeared to be good. Under local anesthesia the stomach was divided below the diaphragm and two gastrostomies were created. He tolerated the procedure well and rapidly improved. The denervated, partially intrathoracic gastric pouch was dependently drained by a tube. (Fig. 1.) The distal gastrostomy drained the duodenum and part of the gastric antrum. Only small amounts of viscid material which contained no acid were collected from the proximal gastrostomy until tube feedings were instituted through the distal gastrostomy about a week after operation. With the tube feedings the volume of gastric secretion from the pouch increased and specimens had a pH of 3.0. The patient tolerated tube feeding in the amount of 300 cc. every ttvo hours beginning at 9 A.M. and ending at :J :I..zI. and he was maintained on this regimen. ‘I’\velve hour collections, S A.M. to 8 P.M., averaged 152.7 (=t8.3) mEq. of total acid over seven consecutive days; the 8 P.M. to S A.M. collections averaged 33.X (* 4.7) mEq. of total acid. The patient was studied a half hour after the second tube feeding at 11 A.M. by the technic diagrammed in Figure 1. He was seated with a
548
Okinaka
SPIROMETER FILLED
WITH
5xco* 95%
0.2
I
CO2
ANALYZER AND
RECORDER
FIG. 1. Diagram of apparatus used to study a patient with a gastric pouch. A record from an actual test is shown; the arrow designates the beginning of the study.
mouthpiece and a nose clip in place and secretions from the gastric pouch were collected for ten minutes while he breathed through a one way circuit. He breathed either room air or a 5 per cent carbon dioxide-95 per cent oxygen gas mixture from a Tissot spirometer which recorded each breath. Expired air was monitored with an infrared carbon dioxide analyzer which was connected to a recorder (an actual record of a study is shown in Figure 1 where the expired air maintains a concentration of 5.0 to 6.5 per cent). Ten minutes was the longest period the patient could breathe into the apparatus comfortably and allowed the collection of about 0.5 mEq. of total acid from the pouch. On repeated examinations by this technic no increase in gastric acid secretion was demonstrated from the pouch with the inhalation of 5 per cent carbon dioxide. If gastric acid secretion is stimulated by elevated tensions of carbon dioxide, these observations suggest that the mechanism is mediated by the vagus nerves. These same observations are, however, also consistent with the hypothesis that increased partial pressures of carbon dioxide have no augmenting effect on gastric acid secretion. It is not possible with our present limited knowledge to be certain which of these suppositions is true. The paucity of cases available for this study was initially disturbing and alternative surgical procedures for the treatment of peptic ulcer were reviewed for the same period of time. Other authors also have had only relatively
small numbers of patients to report. On reviewing our experience there were three interesting aspects to the collected series of cases: (1) the incidence of postoperative pulmonary complications, (2) the age of the patients, and (3) the final outcome. Stein and associates [12] have recently discussed the increased incidence of postoperative pulmonary complications in patients with pre-existing lung disease. The reasons for this, while they are still somewhat obscure, relate in some way to the intrathoracic alterations which occur with upper abdominal operations. There were four postoperative pulmonary complications in the fourteen patients shown in Table I and three of these patients required tracheostomy. The fourteen patients were significantly older (p< 0.01) than the twenty-three patients who were thought to have less serious lung disease and in whom no postoperative pulmonary complications occurred. The two groups however were similar in other respects; both had a majority of ulcers located in the stomach and were operated upon for bleeding. Afflicted with other disease associated with advanced age, the patients noted in Table I died of various causes. One was in critical condition when taken to the operating room and died a short time after operation. Survival, nevertheless, was achieved in many of the patients and good results were obtained. The management of these patients with both chronic lung disease and a complicated peptic ulcer is usually tedious and difficult. OccasionAmerican
Journal of Surgery
Peptic
Ulcer
and
Chronic
ally the ulcer diathesis is severe and the disease, despite all of the provisions made, takes a fatal course as ulcers may in association with other conditions such as liver disease, burns, and sepsis. At times pulmonary insufficiency resulting from chronic bronchitis and pul monary emphysema may be totally refractory to treatment, but usually some improvement can be obtained. This is seen in the case of the sixty-eight year old man; with intensive care the condition of a patient with long-standing pulmonary disease was improved, as demonstrated by partial pressures of 40 mm. Hg of carbon dioxide obtained in this particular patient. In general it is prudent at this time to consider the lung disease and ulcer as separate entities, to treat the peptic ulcer by usual well established principles and to manage the chronic lung disease expectantly by following up the patient closely and by carrying out whatever is indicated. In this situation standard surgical technics should be employed and general anesthesia is preferred. During the time of operation the patient is individually managed by the anesthesiologist who keeps the main airways clear by careful suctioning. manually insures adequate exchange of gases, and maintains high levels of oxygen saturation in the blood with proper mixtures of gases. These patients with respiratory insufficiency can be expected to tolerate the period of the operation. The days immediately after operation are the most difficult and critical. With upper abdominal operations certain structural and functional changes in the lungs are known to occur. These include a decrease in pulmonary compliance, a decrease in lung volumes. a decrease in oxygen saturation, and a change in the pattern of breathing [13,143. While these alterations are usually inconsequential for patients with normal lungs, they become important. in patients with limited pulmonary reserve. Since these changes occur during the days immediately after operation! it is necessary to follow up these patients closely in the early postoperative period. In the past the analysis of arterial blood samples had not been readily available in a general hospital; now, apparatus for the rapid and accurate measurement of blood gases and pH have been developed and these technics are easily employed. The arterial blood in these patients should be monitored. In patients who require tracheostomy, a large-bore, cuff cd
Lung
Disease
tracheostomy tube can be implemented with a small ventilation meter or respirometer described by Wright for measuring tidal air exchange [15,26]. By briefly inflating the cuff on the tracheostomy tube, ventilation can be completely diverted through the ventilation meter which is connected by means of adaptors to the tracheostomy tube; in this way air exchange may be quickly assessed with reason able accuracy. It has been useful to correlate ventilation measured in this fashion with the values of the arterial blood gases and pH drawn at the same time. The values of the arterial blood analysis should be interpreted as serial measurements; carbon dioxide values over 49 mm. Hg may be arbitrarily taken as suggested by Campbell [17] and Scadding [18] as indicating respiratory insufficiency. If the tidal volume falls below 300 cc. usually some form of assisted or controlled respiration is necessary. If ventilatory insufficiency is being treated with a mechanical respirator, the volume of air being delivered to the patient should be known as well as the arterial blood gases and pH while the patient is being ventilated. With the volume-cycled respirators which deliver a specific volume with each stroke, ventilation is determined by a gauge. In other types with pressure and flow-rate gauges, the volume of gas being delivered by the respirator to the patient may be measured by adapting the respirometer or ventilation meter to the expiratory outlet. With the cuff on the trachcostomy tube inflated, the tidal expiratory volume can be observed in this manner. These suggested technics are simple to perform and are convenient ways of monitoring the patient, The necessity of humidification, bronchodilators, frequent suctioning, and high oxygen tensions have been sufficiently m~plxt~izecl in the literature. SUMMARY
Of 689 patients who underwent subtotal gastric resection on the surgical services of The New York Hospital-Cornell Medical Center, there were fourteen patients with significant chronic lung disease who had resection for proved benign ulcers of the stomach or duodenum. These patients were older and as a group showed a high incidence of postoperative pulmonary complications. Survival and good results can be achieved. Patients with chronic lung disease and peptic ulcers
Okinaka are best managed by assuming the two conditions are separate processes and by treating each in accordance with established principles. The results of studies performed on an eightythree year old man with a gastric pouch are also presented. REFERENCES
1. COHEN, A. C. and JENNY, F. S. The frequency of peptic ulcer in patients with chronic pulmonary emphysema. Am. Rev. Resp. Dis., 85: 130, 1962. 2. ELLISON, L. T., ELLISON, R. G., CARTER, C. H., DANIELL, D., JR., and MOORE, V. A., JR. The role of hypercapnia and hypoxia in the etiology of peptic ulceration with chronic obstructive pulmonary emphysema. Am. Rev. Resp. Dis., 89: 909, 1964. 3. GLICK, D. L. and KERN, F., JR. Peptic ulcer and chronic obstructive bronchopulmonary disease. A prospective clinical study of prevalence. Gastroenterology, 47: 153, 1964. 4. LATTS, E. M., CUMMINS,J. E., and ZIEVE, L. Peptic ulcer and pulmonary emphysema. Arch. Int. Med., 97: 576, 1956. 5. XAITOVE, A. and TENNEY, S. M. Effects of hypoxia and hypercapnia on gastric acid secretion in man. Gastroenterology, 43: 181, 1962. 6. SILEN, W., BROWN, W. H., and EISEMAN, B. Peptic ulcer and pulmonary emphysema. Arch. Surg., 78: 897, 1959. 7. WEBER, J, M. and GREGG, L. A. The coincidence of
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benign gastric ulcer and chronic pulmonary disease. Finn. Int. Med., 42: 1026, 1955. The Xew York Hospital-Cornell Medical Center Annual Report, Department of Surgery, 1956 to 1965. OKINAKA, A. J. and GLENN, F. The surgical patient with emphysema and CO2 retention. Axh. Surg., 90: 436, 1965. PLATTS, M. M. Peptic ulceration and gastric acid secretion in patients with chronic respiratory acidosis. Gastroenterology, 38: 317, 1960. ‘ZASLY, L., BAUM, G. L., and RUMBALL, J. M. The incidence of peptic ulceration in chronic obstructive pulmonary emphysema. Dis. Chest, 37: 400, 1960. STEIN, M., KOOTA, G. M., SIMON, M., and FRANK, H. A. Pulmonary evaluation of surgical patients, J.A.M.A., 181:765, 1962. LEWIS, F. J. and WELSH, J. A. Respiratory mechanics in postoperative patients. Surg. Gynec. b Obst., 120: 305, 1965. OKINAKA, A. J. Postoperative pattern of breathing and compliance. Arch. Surg., 92: 887, 1966. WRIGHT, B. M. A respiratory anemometer. J. Physiol., 125: 25, 1955. DUNN, J. F. and EZI-ASHI, T. I. The accuracy of the respirometer and Ventigrator. Brit. J. Anesth., 34: 422, 1962. CAMPBELL,E. J. M. Respiratory failure. &it. M. J., 1: 1451, 1965. SCADDING, J. G. Patterns of respiratory insufficiency. Lnncet, 1: 701, 1966.
Amevican
Journal
ofSurgery