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The Choice of Treatment in Gastric and Duodenal Ulcers
Medical Clinics of North America May, 1942. New York Number
THE CHOICE OF TREATMENT IN GASTRIC AND DUODENAL ULCERS* J. WILLIAM HINTON, M.D., F.A.C.S.t
THOSE physicians interested in the care of patients suffering from gastric or duodenal ulcers, whether they be internists or surgeons, have come to a more general understanding of the limitations of both medical and surgical treatment during the past decade. This has been brought about by combined clinics for the treatment of both medical and surgical patients with ulcers, in which the personnel consists of both internists and surgeons. In such a clinic the good results from each method of treatment are soon appreciated and the bad results are evaluated so that one does not repeat the same errors. It has been my privilege to spend fourteen years working in such a clinic. When the clinic was started in January, 1928, we believed, as a result of what we had seen in our surgical follow-up clinic, that operations generally gave poor results. For that reason we would not advise operative intervention in a patient with an ulcer unless the pain was so severe one was forced to operate by request of the patient. We immediately eliminated such "so-called" indicatj.ons as pyloric obstruction, gastric ulcer, and severe massive hemorrhage without pain and advised medical care for all of these conditions. The above principles have not been deviated from during the entire fourteen years. I felt from the beginning that medical care for the uncomplicated ulcer gave excellent results. I am more convinced of that now than in the early years of the clinic. From our .. From the Fourth Surgical Division, Bellevue Hospital.
t Associate Professor of Clinical Surgery, Post Graduate School of
Columbia University; Visiting Surgeon, Bellevue Hospital. 671
672
J.
WILLIAM HlNTON
observations, if a patient with an ulcer is seen early in the course of the disease, meaning the first few months or year, and is put on medical management, and if he cooperates in the treatment, the chances of avoiding surgery over a tenyear period are excellent. Of course, if the patient with ulcer is first seen late in the course of the disease, five years or longer after the onset, then the chances of improvement from medical management are greatly diminished. In these instances the disease has generally progressed beyond the stage of a simple ulcer. Penetration of the entire wall of the stomach or duodenum has probably occurred and an associated pancreatitis exists which is causing the patient to seek medical aid. In these circumstances one cannot expect a cure by dietary management. It is the failure to appreciate these very fundamental principles which has led to so much confusion about good and poor results from surgical procedures, particularly gastroenterostomy. In the first few years of our clinic, 1928 to 1931 inclusive, gastro-enterostomy alone was practiced, but we were soon to see a large number of poor results which we could not at first explain. During this period of five years we referred twenty-nine cases for gastro-enterostomy, and in the fifth year an occasional case for subtotal resection. As all patients were transferred to the ulcer clinic after operation, we had there a large group of gastro-enterostomies under observation. The results from gastro-enterostomy were so generally unsatisfactory that it was discontinued in 1932 and since 1933 subtotal resections have been done exclusively. One will immediately challenge this stand but before forming judgment it would be well to examine all of the data we have. A study of our cases in these early years of the clinic revealed that the percentage of operative cases was extremely small. We came to the realization that we were really performing operations only on patients with the complication of an ulcer, namely chronic pancreatitis, which could not be cured by short-circuiting procedures. In other words, if patients do not come to operation until the floor of the ulcer is formed by an adjacent viscus, which is usually the pancreas, then the failure of gastro-enterostomy is inevitable. On
TREATMENT IN GASTRIC AND DUODENAL ULCERS
673
the other hand, if gastro-enterostomy is performed before such a complication has occurred a good result may be expected provided the patient is fortunate enough to avoid a gastrojejunal ulcer. It is our belief, however, that the cases which are cured by gastro-enterostomy can be cured by a simpler method of treatment, namely, dietary management. There is very little evidence that gastro-enterostomy restores the patient to health and an earning capacity quicker than does medical care. The findings in 106 gastro-enterostomies followed for an average of 7.1 years have been reported. 1 We found that only 24.5 per cent of the patients were cured. A letter follow-up or a recall of a group of patients for one thorough examination to determine the results of operation is misleading as to the true clinical picture over a period of years. Having concluded in 1932 that gastro-enterostomy seldom cures a patient with a chronic ulcer, we felt justified in performing subtotal resection in all cases of chronic gastric and duodenal ulcers for which operation was indicated. Ninety patients have since been subjected to this procedure. The results are very satisfactory and so far gastrojejunal ulcer has not been observed in the cases which we have followed. Pernicious anemia has developed in one patient, who is being treated for that condition at the present time. We are now evaluating our results from subtotal resections and they will be reported in the near future. It should be emphasized that in subtotal resection we always remove the ulcer whether it be duodenal or gastric. When the ulcer is left attached to the pancreas the results are not so good. In any evaluation of subtotal resection one should definitely distinguish between those cases in which the ulcer has been left attached and those in which it has been completely removed. The former operation is a compromise procedure and the latter a complete surgical procedure . . The question of medical or surgical management of gastric ulcer when it is first diagnosed is still being debated. We have discussed this problem previously,2 and it will suffice to say here that gastric ulcers respond to medical care more readily
674
J.
WILLIAM HINTON
than do duodenal ulcers. If there is the least doubt as to the differential diagnosis between gastric ulcer and gastric carcinoma, an immediate operation is advised, but otherwise these cases are treated medically and an operation is advised only for uncontrollable pain. In about 10 per cent of gastric ulcers the differential diagnosis between an inflammatory lesion and a gastric cancer is difficult. The acute perforated ulcers, whether they be gastric or duodenal, will require immediate surgical intervention after treating the shock by intravenous infusions of fluids or plasma. The surgical procedure consists only in simple closure of the perforation, after which the ulcer is treated as a medical problem, in the same manner as uncomplicated ulcer. If gastro-enterostomy is added to simple closure the incidence of gastrojejunal ulcer is higher than in instances of chronic duodenal ulcers treated by gastro-enterostomy. The procedure cannot be too strongly condemned. Massive hemorrhage should be treated conservatively with transfusions, infusions, dietary management and sedation. The majority of patients will recover, but a small percentage of massive hemorrhages will prove fatal under medical care. The percentage will vary with different hospitals and also with the type of case. I am discussing cases in a municipal hospital with an active ambulance service and my remarks may not hold true for a hospital without an ambulance service. Our cases consist of those with secondary anemia with the red cell count below 3,000,000 and the hemoglobin below 60 per cent, and the patient is in shock. In a previous report,3 based upon 165 cases in a twelve-year period, we found that 10 per cent proved fatal. Since 1937 four patients with massive hemorrhage have been operated upon in the active stages of hemorrhage and all survived. In three instances subtotal resection was performed, as it was the only means of controlling the hemorrhage. Other procedures such as gastro-enterostomy and attempts to ligate the gastroduodenal artery would have been futile, since in two instances posterior duodenal ulcers were complicated by marked chronic pancreatitis and .in one of these the bleeding was from the superior pancreaticoduo-
TREATMENT IN GASTRIC AND DUODENAL ULCERS
675
denal artery and in the other from a large branch of this artery'. In another case a gastric ulcer on the lesser curvature had perforated the stomach wall and a large branch of the left gastric artery was bleeding. The final case was a gastrojejunal ulcer which was perforating into the mesentery of the small gut and a large artery was bleeding from the mesentery. The gastro-enterostomy was dissociated. Since 1937 we have not lost a case from massive hemorrhage and we feel certain that the four cases described would have proved fatal if operation had not been done. There is a method of deciding the indications for surgical intervention in massive hemorrhage; this is the transfusion test. Transfusions in amounts of 1000 to 5000 cc. of blood are given by the indirect method and if the pulse and blood pressure have not improved or if they have become worse it is a fair indication that we have arterial bleeding, which will prove fatal. The cases of massive hemorrhage needing operative intervention as a life-saving procedure are very few but they do occur and one must be ready to meet the situation when the need arises. BI BLIOGRAPHY
J. vVilliam: The Results of Gastroenterostomy in Gastric and Duodenal Ulcers. Surgery, 7: 647--656 (May) 1940. 2. Hinton, J. William and Trubek, Max: The Transformation of Gastric Ulcer into Gastric Carcinoma. Surg., Gynec. & Obst., 64: 16--21 (Jan.) 1937. 3. Hinton, J. William: Massive Hemorrhage in Peptic Ulcer; The Transfusion Test for Determining the Necessity of Operation. Ann. Surg., 110 (Sept.) 1939. 1. Church, Reynold E. and Hinton,
THE CHOICE OF TREATMENT IN GASTRIC AND DUODENAL ULCERS* J. WILLIAM HINTON, M.D., F.A.C.S.t
THOSE physicians interested in the care of patients suffering from gastric or duodenal ulcers, whether they be internists or surgeons, have come to a more general understanding of the limitations of both medical and surgical treatment during the past decade. This has been brought about by combined clinics for the treatment of both medical and surgical patients with ulcers, in which the personnel consists of both internists and surgeons. In such a clinic the good results from each method of treatment are soon appreciated and the bad results are evaluated so that one does not repeat the same errors. It has been my privilege to spend fourteen years working in such a clinic. When the clinic was started in January, 1928, we believed, as a result of what we had seen in our surgical follow-up clinic, that operations generally gave poor results. For that reason we would not advise operative intervention in a patient with an ulcer unless the pain was so severe one was forced to operate by request of the patient. We immediately eliminated such "so-called" indicatj.ons as pyloric obstruction, gastric ulcer, and severe massive hemorrhage without pain and advised medical care for all of these conditions. The above principles have not been deviated from during the entire fourteen years. I felt from the beginning that medical care for the uncomplicated ulcer gave excellent results. I am more convinced of that now than in the early years of the clinic. From our .. From the Fourth Surgical Division, Bellevue Hospital.
t Associate Professor of Clinical Surgery, Post Graduate School of
Columbia University; Visiting Surgeon, Bellevue Hospital. 671
672
J.
WILLIAM HlNTON
observations, if a patient with an ulcer is seen early in the course of the disease, meaning the first few months or year, and is put on medical management, and if he cooperates in the treatment, the chances of avoiding surgery over a tenyear period are excellent. Of course, if the patient with ulcer is first seen late in the course of the disease, five years or longer after the onset, then the chances of improvement from medical management are greatly diminished. In these instances the disease has generally progressed beyond the stage of a simple ulcer. Penetration of the entire wall of the stomach or duodenum has probably occurred and an associated pancreatitis exists which is causing the patient to seek medical aid. In these circumstances one cannot expect a cure by dietary management. It is the failure to appreciate these very fundamental principles which has led to so much confusion about good and poor results from surgical procedures, particularly gastroenterostomy. In the first few years of our clinic, 1928 to 1931 inclusive, gastro-enterostomy alone was practiced, but we were soon to see a large number of poor results which we could not at first explain. During this period of five years we referred twenty-nine cases for gastro-enterostomy, and in the fifth year an occasional case for subtotal resection. As all patients were transferred to the ulcer clinic after operation, we had there a large group of gastro-enterostomies under observation. The results from gastro-enterostomy were so generally unsatisfactory that it was discontinued in 1932 and since 1933 subtotal resections have been done exclusively. One will immediately challenge this stand but before forming judgment it would be well to examine all of the data we have. A study of our cases in these early years of the clinic revealed that the percentage of operative cases was extremely small. We came to the realization that we were really performing operations only on patients with the complication of an ulcer, namely chronic pancreatitis, which could not be cured by short-circuiting procedures. In other words, if patients do not come to operation until the floor of the ulcer is formed by an adjacent viscus, which is usually the pancreas, then the failure of gastro-enterostomy is inevitable. On
TREATMENT IN GASTRIC AND DUODENAL ULCERS
673
the other hand, if gastro-enterostomy is performed before such a complication has occurred a good result may be expected provided the patient is fortunate enough to avoid a gastrojejunal ulcer. It is our belief, however, that the cases which are cured by gastro-enterostomy can be cured by a simpler method of treatment, namely, dietary management. There is very little evidence that gastro-enterostomy restores the patient to health and an earning capacity quicker than does medical care. The findings in 106 gastro-enterostomies followed for an average of 7.1 years have been reported. 1 We found that only 24.5 per cent of the patients were cured. A letter follow-up or a recall of a group of patients for one thorough examination to determine the results of operation is misleading as to the true clinical picture over a period of years. Having concluded in 1932 that gastro-enterostomy seldom cures a patient with a chronic ulcer, we felt justified in performing subtotal resection in all cases of chronic gastric and duodenal ulcers for which operation was indicated. Ninety patients have since been subjected to this procedure. The results are very satisfactory and so far gastrojejunal ulcer has not been observed in the cases which we have followed. Pernicious anemia has developed in one patient, who is being treated for that condition at the present time. We are now evaluating our results from subtotal resections and they will be reported in the near future. It should be emphasized that in subtotal resection we always remove the ulcer whether it be duodenal or gastric. When the ulcer is left attached to the pancreas the results are not so good. In any evaluation of subtotal resection one should definitely distinguish between those cases in which the ulcer has been left attached and those in which it has been completely removed. The former operation is a compromise procedure and the latter a complete surgical procedure . . The question of medical or surgical management of gastric ulcer when it is first diagnosed is still being debated. We have discussed this problem previously,2 and it will suffice to say here that gastric ulcers respond to medical care more readily
674
J.
WILLIAM HINTON
than do duodenal ulcers. If there is the least doubt as to the differential diagnosis between gastric ulcer and gastric carcinoma, an immediate operation is advised, but otherwise these cases are treated medically and an operation is advised only for uncontrollable pain. In about 10 per cent of gastric ulcers the differential diagnosis between an inflammatory lesion and a gastric cancer is difficult. The acute perforated ulcers, whether they be gastric or duodenal, will require immediate surgical intervention after treating the shock by intravenous infusions of fluids or plasma. The surgical procedure consists only in simple closure of the perforation, after which the ulcer is treated as a medical problem, in the same manner as uncomplicated ulcer. If gastro-enterostomy is added to simple closure the incidence of gastrojejunal ulcer is higher than in instances of chronic duodenal ulcers treated by gastro-enterostomy. The procedure cannot be too strongly condemned. Massive hemorrhage should be treated conservatively with transfusions, infusions, dietary management and sedation. The majority of patients will recover, but a small percentage of massive hemorrhages will prove fatal under medical care. The percentage will vary with different hospitals and also with the type of case. I am discussing cases in a municipal hospital with an active ambulance service and my remarks may not hold true for a hospital without an ambulance service. Our cases consist of those with secondary anemia with the red cell count below 3,000,000 and the hemoglobin below 60 per cent, and the patient is in shock. In a previous report,3 based upon 165 cases in a twelve-year period, we found that 10 per cent proved fatal. Since 1937 four patients with massive hemorrhage have been operated upon in the active stages of hemorrhage and all survived. In three instances subtotal resection was performed, as it was the only means of controlling the hemorrhage. Other procedures such as gastro-enterostomy and attempts to ligate the gastroduodenal artery would have been futile, since in two instances posterior duodenal ulcers were complicated by marked chronic pancreatitis and .in one of these the bleeding was from the superior pancreaticoduo-
TREATMENT IN GASTRIC AND DUODENAL ULCERS
675
denal artery and in the other from a large branch of this artery'. In another case a gastric ulcer on the lesser curvature had perforated the stomach wall and a large branch of the left gastric artery was bleeding. The final case was a gastrojejunal ulcer which was perforating into the mesentery of the small gut and a large artery was bleeding from the mesentery. The gastro-enterostomy was dissociated. Since 1937 we have not lost a case from massive hemorrhage and we feel certain that the four cases described would have proved fatal if operation had not been done. There is a method of deciding the indications for surgical intervention in massive hemorrhage; this is the transfusion test. Transfusions in amounts of 1000 to 5000 cc. of blood are given by the indirect method and if the pulse and blood pressure have not improved or if they have become worse it is a fair indication that we have arterial bleeding, which will prove fatal. The cases of massive hemorrhage needing operative intervention as a life-saving procedure are very few but they do occur and one must be ready to meet the situation when the need arises. BI BLIOGRAPHY
J. vVilliam: The Results of Gastroenterostomy in Gastric and Duodenal Ulcers. Surgery, 7: 647--656 (May) 1940. 2. Hinton, J. William and Trubek, Max: The Transformation of Gastric Ulcer into Gastric Carcinoma. Surg., Gynec. & Obst., 64: 16--21 (Jan.) 1937. 3. Hinton, J. William: Massive Hemorrhage in Peptic Ulcer; The Transfusion Test for Determining the Necessity of Operation. Ann. Surg., 110 (Sept.) 1939. 1. Church, Reynold E. and Hinton,