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The Surgical Management of Gastric Ulcer
Symposium on Acid-Peptic Disease
The Surgical Management of Gastric U leer
O. Theron Clagett, M.D.
In the past, use of the term "peptic ulcer" and acceptance of the concept that duodenal ulcer and gastric ulcer developed from the same cause has led to much confusion. Fortunately, it is now generally recognized that there are more differences than similarities between these lesions and that it is much more rational to consider them as separate entities.
CHARACTERISTICS AND PREOPERATIVE DIAGNOSIS Gastric ulcer tends to occur in older persons. It may be associated with chronic atrophic gastritis, whereas duodenal ulcer is not. Patients with gastric ulcer tend to have less gastric acidity than normal, whereas duodenal-ulcer patients almost always have more than normal. From a clinical standpoint, duodenal ulcer seems to occur much more commonly than gastric ulcer; yet in autopsy studies the incidence of the two lesions is almost identical. The reason for this discrepancy is not clear, but it may be that some acute gastric ulcers occur as a terminal event in seriously ill patients. Gastric ulcer occurs in men about three times as frequently as in women and most commonly develops in the fourth to sixth decades of life. Gastric ulcers can occur in any part of the stomach, but about 75% are found in the region of the lesser curvature. Despite extensive investigation, the cause of gastric ulcer is not entirely clear. Dragstedt's3 concept of it is attractive, however. He postulated that gastric ulcers develop primarily as a result of antral stasis with concomitant hypersecretion of gastric juice due to gastrin stimulation. The antral stasis, he said, may be due to gastric atony resulting from hypofunction of the motor fibers of the vagal nerves. Johnson6 suggested that gastric ulcer develops because of a deficiency in gastric secretion of protective mucus. Capper has postulated that reflux of duodenal secretions through the pylorus into the stomach is the important factor. He believed that the Surgical Clinics of North America - VoL 51, No.4, August 1971
901
902
o.
THERON CLAGETT
alkaline duodenal secretions have the same relationship to the genesis of gastric ulcer as the acid gastric secretions have to the genesis of duodenal ulcer. One may hope that future investigations will establish more definitely the etiology of these ulcerating lesions. The symptoms and clinical history of gastric ulcers are well known and will not be discussed here. The clinical manifestations lead to roentgenologic investigation of the upper gastrointestinal tract, and almost invariably the presence of an ulcerating gastric lesion is first established by the radiologist. We are fortunate in having available such a precise and accurate procedure for detecting gastric ulcers and measuring their response to medical treatment. Studies of gastric acidity should be performed. As mentioned previously, gastric secretion of acid in patients with gastric ulcer is usually much less than in patients with duodenal ulcer. A low gastricacid value or anacidity, however, strongly suggests that the ulcerating gastric lesion may be an ulcerating carcinoma and indicates early surgical resection of the lesion rather than a trial of medical treatment. For many years, gastroscopy has been used extensively for direct visualization of ulcerating gastric lesions. More recently very sophisticated instruments have been developed and used enthusiastically. The new flexible fiberoptic gastroscopes have overcome many of the limitations of the older instruments. It is now possible to visualize practically all areas of the stomach accurately, to make photographs of the ulcer, and even obtain biopsy specimens directly from the lesion. Cytologic study of gastric secretions, searching for malignant cells, has also been developed in some centers in an effort to distinguish between malignant and benign gastric ulcers.
SURGICAL VERSUS MEDICAL TREATMENT In the past it was generally recognized and accepted that approximately 10% of the lesions that appeared to be benign gastric ulcers on radiologic and gastroscopic examination would actually be ulcerating carcinomas. This fact encouraged and supported a policy of early surgical intervention. With the diagnostic techniques now available, however, the rate of diagnostic accuracy has improved considerably, and a trial of medical treatment can now be supported with more confidence. But it must still be recognized that perfect accuracy still is not possible in distinguishing between benign and malignant ulcers and that prolonged medical treatment for gastric ulcers that do not heal promptly should be condemned. At present, if all diagnostic tests indicate that an ulcerating gastric lesion is benign, a 2-week trial of rigid medical management seems reasonable. And if roentgenologic study shows the crater is 50% smaller at the end of the 2 weeks, medical treatment and observation may be continued. Failure to obtain such a response warrants surgical intervention without further delay. However, it should be pointed out that the medical treatment of
SURGICAL MANAGEMENT OF GASTRIC ULCER
903
gastric ulcers in general leaves much to be desired. Recurrent trouble is the rule. Welch and Burke,l2 after reviewing various reported series of patients with gastric ulcers treated medically, concluded that lasting good results were obtained in only 20 to 30% of cases. Angel, Giacobine, and Jordanl have reported a series of 267 patients diagnosed clinically as having benign gastric ulcer. Medical therapy was given initially to 196 patients; but it kept only 25% of them asymptomatic, whereas 5% died of ulcer complications within a year, 20% had severe persisting symptoms, and another 37% ultimately were operated upon. Of 144 patients operated upon, 7 were found to have carcinoma. Gastric resection for benign gastric ulcer was performed in 121 cases, with mortality of 1.6% and good to excellent results in 95%. The controversy about medical or surgical treatment for ulcerating gastric lesions goes on unceasingly. Even though more reliable diagnosis makes trials of medical management safer, as mentioned, it should be pointed out that ulcerating lesions larger than 2.5 to 3 cm rarely heal with medical management and most patients with lesions of this size should be referred promptly for surgical consultation. From an economic viewpoint, it is important to realize that medical treatment can easily impose a financial burden as great as or greater than that of surgical treatment. The period of hospitalization required for proper medical treatment is almost invariably longer than that required for operation, and the period of disability is almost as long. The cost of repeated radiologic examinations, gastroscopic visualizations, gastric cytologic studies, etc., necessary for proper monitoring of an ulcerating gastric lesion, often exceeds the cost of operation. It must also be emphasized again that medical management of benign gastric ulcer provides a lasting good result in only 20 to 30% of patients and that many of the remainder come to delayed surgical treatment with a compounding of the expense of hospitalization and disability. Of course if surgical treatment for benign gastric ulcer carried a great risk or if it did not provide good clinical results, there would be more justification for prolonged efforts to treat this lesion medically. However, surgical treatment of gastric ulcer has been performed in many centers with a risk of only 1 or 2%; and in most reported experience good to excellent results have been obtained in 90 to 95% of patients surgically treated. When one compares critically the results of medical and surgical treatment for benign gastric ulcer, it becomes apparent that (1) the risk of development of fatal complications during medical management is as great or even greater than the risk of surgical treatment; (2) medical treatment usually involves a greater period of disability and a greater total financial burden than does surgical treatment; (3) lasting good clinical results occur at least three times as frequently with surgical treatment as with medical treatment; and (4) a policy of taking surgical measures against ulcerating gastric lesions provides early effective treatment for those that prove malignant on pathologic examination, even though they appeared benign by all available means of preoperative study. It seems obvious that a majority of ulcerating gastric lesions can
o.
904
THERON CLAGETT
be dealt with most effectively by surgical means or indeed will require surgery. However, I do recognize that a limited trial of medical treatment is justifiable in carefully selected circumstances.
SURGICAL PROCEDURES A great variety of surgical procedures have been used rather extensively in management of patients with benign, chronic gastric ulcer. Obviously no single surgical procedure is suitable in all cases. The procedure must vary, to match the size and location of the ulcer and the presence or absence of associated pathology such as duodenal ulcer or diaphragmatic hernia. In some instances, even the sex of the patient may influence the choice of procedure. If one accepts completely Dragstedt's concept that gastric retention is the primary mechanism producing gastric ulcer, a procedure consisting of local excision of the ulcer and a provision for drainage, such as pyloroplasty or gastrojejunostomy, should be appropriate. And these procedures have been used widely. As long ago as 1924 Strauss8 reported 21 patients treated by excision of the ulcer and pyloroplasty who had had no recurrence in 8 years following. In 1934 Walton1oreported 325 patients treated by excision and gastrojejunostomy with recurrence of ulcer in only 1.8%. However, results reported by others have been much less favorable; and this operation is not generally accepted now as adequate. The development of vagotomy with some type of drainage procedure for surgical management of duodenal ulcer made it inevitable that vagotomy be applied also in the management of gastric ulcer. Weinbergl l reported a series of patients with gastric ulcer treated by local excision of the ulcer, vagotomy, and some type of drainage procedure and followed up for 3 to 9 years. Ulcer recurred in 7% of these patients. Stemmer and associates7 more recently reported a series of patients treated in the same way with a 40% incidence of recurrent ulceration. Although excision of the ulcer, vagotomy, and a drainage procedure may seem attractive theoretically, it does not appear to have been very successful practically. Furthermore, when one considers some of the side effects that may follow vagotomy, such as diarrhea, it seems best to avoid vagotomy for the treatment of gastric ulcer unless it is required anyway by a concomitant duodenal ulcer.
Method of Choice In my opinion, distal partial gastric resection, including the ulcerating gastric lesion, is the surgical treatment of choice for most benign gastric ulcers. Whether a Billroth I or Billroth II procedure is used for restoration of gastrointestinal continuity does not seem to have much effect on the results. I personally prefer a Billroth I type of operation when feasible. However, no gastroduodenal anastomosis should be made unless there is a healthy, unscarred, mobile duodenum available for it; and there should never be tension upon the anastomosis. The extent of the resection must be determined to some degree by the location of the
SURGICAL MANAGEMENT OF GASTRIC ULCER
905
ulcer, but resection of more than 50 to 60% of the stomach should be avoided, if possible. In most instances, even with lesions rather high on the lesser curvature, Hofmeister or Schoemaker modifications of the Billroth II or Billroth I operation permit adequate resection of the ulcer with preservation of a very adequate gastric remnant. Recurrences of gastric ulcer after either Billroth I or Billroth II gastric resection are rare. Tanners reported only 2 recurrences after 800 Billroth I resections. Harkins and associates,4 after 140 resections, found only 1 recurrence. Johnson5 had no recurrences in 140 patients who had undergone Billroth II resection. Most competent surgeons can perform such resection with a surgical risk of less than 2%. It is difficult to see how the results of surgical treatment of gastric ulcer can be improved much by procedures other than the classic Billroth I or Billroth II operations and their Schoemaker and Hofmeister modifications. Gastric ulcers high on the lesser curvature, where it approaches the esophagogastric junction, may pose a special problem. Fortunately, not many ulcers develop in this region; and often surgical exploration reveals that they are not actually so high as they may have appeared on radiologic examination. Even these high gastric ulcers can be resected by appropriate tailoring of the lesser-curvature resection, preserving the fundus and the greater curvature for a very adequate gastric reservoir. If the ulcer is so close to the esophagogastric junction that resection cannot be achieved without compromise of this structure, multiple biopsies of the lesion may rule out possible malignancy; and then vagotomy with antrectomy or a gastric drainage procedure may be done. Satisfactory results with healing of the ulcer after this type of management have been reported.
CONCLUSIONS I would emphasize that for ulcerating lesions of the stomach surgical treatment generally is better than medical. In most instances standard distal gastrectomy of either the Billroth I or Billroth II type provides good results at minimal risk.
REFERENCES 1. Angel RT, Giacobine JW, Jordan GL Jr: A current evaluation of the problem of gastric ulcers. Amer J Surg 114:730-735, 1967 2. Capper WM: Factors in the pathogenesis of gastric ulcer. Ann Roy Coll Surg Eng 40:2135,1967 3. Dragstedt LR: A concept of the etiology of gastric and duodenal ulcers. Gastroenterology 30:208-214,1956 4. Harkins HN, Schmitz EJ, Nyhus LM, et al: The Billroth I gastric resection: experimental studies and clinical observations on 291 cases. Ann Surg 140:405-424, 1954 5. Johnson HD: Billroth-I and Polya operations (letter to the editor). Lancet 1:298, 1956. 6. Johnson HD: The pathogenesis of peptic ulcers. Lancet 2:515-517,1957 7. Stemmer EA, Zahn RL, Hom LW, et al: Vagotomy and drainage procedures for gastric ulcer. Arch Surg (Chicago) 96:586-592,1968
906
O. THERON CLAGETT
8. Strauss AA: Longitudinal resection of the lesser curvature with resection of pyloric sphincter for gastric ulcer: an experimental and clinical study. JAMA 82: 1765-1770, 1924 9. Tanner NC: Non-malignant affections of the upper stomach. Ann Roy Coll Surg Eng 10:45-60,1952 10. Walton AJ: Failures of gastric surgery. Lancet 1 :893-897,1934 11. Weinberg JA: Cited by Harkins HN, Nyhus LM: Surgery of the Stomach and Duodenum. Boston, Little, Brown & Company, 1962, p 167 12. Welch CF, Burke JF: An appraisal of the treatment of gastric ulcer. Surgery 44:943958,1958
The Surgical Management of Gastric U leer
O. Theron Clagett, M.D.
In the past, use of the term "peptic ulcer" and acceptance of the concept that duodenal ulcer and gastric ulcer developed from the same cause has led to much confusion. Fortunately, it is now generally recognized that there are more differences than similarities between these lesions and that it is much more rational to consider them as separate entities.
CHARACTERISTICS AND PREOPERATIVE DIAGNOSIS Gastric ulcer tends to occur in older persons. It may be associated with chronic atrophic gastritis, whereas duodenal ulcer is not. Patients with gastric ulcer tend to have less gastric acidity than normal, whereas duodenal-ulcer patients almost always have more than normal. From a clinical standpoint, duodenal ulcer seems to occur much more commonly than gastric ulcer; yet in autopsy studies the incidence of the two lesions is almost identical. The reason for this discrepancy is not clear, but it may be that some acute gastric ulcers occur as a terminal event in seriously ill patients. Gastric ulcer occurs in men about three times as frequently as in women and most commonly develops in the fourth to sixth decades of life. Gastric ulcers can occur in any part of the stomach, but about 75% are found in the region of the lesser curvature. Despite extensive investigation, the cause of gastric ulcer is not entirely clear. Dragstedt's3 concept of it is attractive, however. He postulated that gastric ulcers develop primarily as a result of antral stasis with concomitant hypersecretion of gastric juice due to gastrin stimulation. The antral stasis, he said, may be due to gastric atony resulting from hypofunction of the motor fibers of the vagal nerves. Johnson6 suggested that gastric ulcer develops because of a deficiency in gastric secretion of protective mucus. Capper has postulated that reflux of duodenal secretions through the pylorus into the stomach is the important factor. He believed that the Surgical Clinics of North America - VoL 51, No.4, August 1971
901
902
o.
THERON CLAGETT
alkaline duodenal secretions have the same relationship to the genesis of gastric ulcer as the acid gastric secretions have to the genesis of duodenal ulcer. One may hope that future investigations will establish more definitely the etiology of these ulcerating lesions. The symptoms and clinical history of gastric ulcers are well known and will not be discussed here. The clinical manifestations lead to roentgenologic investigation of the upper gastrointestinal tract, and almost invariably the presence of an ulcerating gastric lesion is first established by the radiologist. We are fortunate in having available such a precise and accurate procedure for detecting gastric ulcers and measuring their response to medical treatment. Studies of gastric acidity should be performed. As mentioned previously, gastric secretion of acid in patients with gastric ulcer is usually much less than in patients with duodenal ulcer. A low gastricacid value or anacidity, however, strongly suggests that the ulcerating gastric lesion may be an ulcerating carcinoma and indicates early surgical resection of the lesion rather than a trial of medical treatment. For many years, gastroscopy has been used extensively for direct visualization of ulcerating gastric lesions. More recently very sophisticated instruments have been developed and used enthusiastically. The new flexible fiberoptic gastroscopes have overcome many of the limitations of the older instruments. It is now possible to visualize practically all areas of the stomach accurately, to make photographs of the ulcer, and even obtain biopsy specimens directly from the lesion. Cytologic study of gastric secretions, searching for malignant cells, has also been developed in some centers in an effort to distinguish between malignant and benign gastric ulcers.
SURGICAL VERSUS MEDICAL TREATMENT In the past it was generally recognized and accepted that approximately 10% of the lesions that appeared to be benign gastric ulcers on radiologic and gastroscopic examination would actually be ulcerating carcinomas. This fact encouraged and supported a policy of early surgical intervention. With the diagnostic techniques now available, however, the rate of diagnostic accuracy has improved considerably, and a trial of medical treatment can now be supported with more confidence. But it must still be recognized that perfect accuracy still is not possible in distinguishing between benign and malignant ulcers and that prolonged medical treatment for gastric ulcers that do not heal promptly should be condemned. At present, if all diagnostic tests indicate that an ulcerating gastric lesion is benign, a 2-week trial of rigid medical management seems reasonable. And if roentgenologic study shows the crater is 50% smaller at the end of the 2 weeks, medical treatment and observation may be continued. Failure to obtain such a response warrants surgical intervention without further delay. However, it should be pointed out that the medical treatment of
SURGICAL MANAGEMENT OF GASTRIC ULCER
903
gastric ulcers in general leaves much to be desired. Recurrent trouble is the rule. Welch and Burke,l2 after reviewing various reported series of patients with gastric ulcers treated medically, concluded that lasting good results were obtained in only 20 to 30% of cases. Angel, Giacobine, and Jordanl have reported a series of 267 patients diagnosed clinically as having benign gastric ulcer. Medical therapy was given initially to 196 patients; but it kept only 25% of them asymptomatic, whereas 5% died of ulcer complications within a year, 20% had severe persisting symptoms, and another 37% ultimately were operated upon. Of 144 patients operated upon, 7 were found to have carcinoma. Gastric resection for benign gastric ulcer was performed in 121 cases, with mortality of 1.6% and good to excellent results in 95%. The controversy about medical or surgical treatment for ulcerating gastric lesions goes on unceasingly. Even though more reliable diagnosis makes trials of medical management safer, as mentioned, it should be pointed out that ulcerating lesions larger than 2.5 to 3 cm rarely heal with medical management and most patients with lesions of this size should be referred promptly for surgical consultation. From an economic viewpoint, it is important to realize that medical treatment can easily impose a financial burden as great as or greater than that of surgical treatment. The period of hospitalization required for proper medical treatment is almost invariably longer than that required for operation, and the period of disability is almost as long. The cost of repeated radiologic examinations, gastroscopic visualizations, gastric cytologic studies, etc., necessary for proper monitoring of an ulcerating gastric lesion, often exceeds the cost of operation. It must also be emphasized again that medical management of benign gastric ulcer provides a lasting good result in only 20 to 30% of patients and that many of the remainder come to delayed surgical treatment with a compounding of the expense of hospitalization and disability. Of course if surgical treatment for benign gastric ulcer carried a great risk or if it did not provide good clinical results, there would be more justification for prolonged efforts to treat this lesion medically. However, surgical treatment of gastric ulcer has been performed in many centers with a risk of only 1 or 2%; and in most reported experience good to excellent results have been obtained in 90 to 95% of patients surgically treated. When one compares critically the results of medical and surgical treatment for benign gastric ulcer, it becomes apparent that (1) the risk of development of fatal complications during medical management is as great or even greater than the risk of surgical treatment; (2) medical treatment usually involves a greater period of disability and a greater total financial burden than does surgical treatment; (3) lasting good clinical results occur at least three times as frequently with surgical treatment as with medical treatment; and (4) a policy of taking surgical measures against ulcerating gastric lesions provides early effective treatment for those that prove malignant on pathologic examination, even though they appeared benign by all available means of preoperative study. It seems obvious that a majority of ulcerating gastric lesions can
o.
904
THERON CLAGETT
be dealt with most effectively by surgical means or indeed will require surgery. However, I do recognize that a limited trial of medical treatment is justifiable in carefully selected circumstances.
SURGICAL PROCEDURES A great variety of surgical procedures have been used rather extensively in management of patients with benign, chronic gastric ulcer. Obviously no single surgical procedure is suitable in all cases. The procedure must vary, to match the size and location of the ulcer and the presence or absence of associated pathology such as duodenal ulcer or diaphragmatic hernia. In some instances, even the sex of the patient may influence the choice of procedure. If one accepts completely Dragstedt's concept that gastric retention is the primary mechanism producing gastric ulcer, a procedure consisting of local excision of the ulcer and a provision for drainage, such as pyloroplasty or gastrojejunostomy, should be appropriate. And these procedures have been used widely. As long ago as 1924 Strauss8 reported 21 patients treated by excision of the ulcer and pyloroplasty who had had no recurrence in 8 years following. In 1934 Walton1oreported 325 patients treated by excision and gastrojejunostomy with recurrence of ulcer in only 1.8%. However, results reported by others have been much less favorable; and this operation is not generally accepted now as adequate. The development of vagotomy with some type of drainage procedure for surgical management of duodenal ulcer made it inevitable that vagotomy be applied also in the management of gastric ulcer. Weinbergl l reported a series of patients with gastric ulcer treated by local excision of the ulcer, vagotomy, and some type of drainage procedure and followed up for 3 to 9 years. Ulcer recurred in 7% of these patients. Stemmer and associates7 more recently reported a series of patients treated in the same way with a 40% incidence of recurrent ulceration. Although excision of the ulcer, vagotomy, and a drainage procedure may seem attractive theoretically, it does not appear to have been very successful practically. Furthermore, when one considers some of the side effects that may follow vagotomy, such as diarrhea, it seems best to avoid vagotomy for the treatment of gastric ulcer unless it is required anyway by a concomitant duodenal ulcer.
Method of Choice In my opinion, distal partial gastric resection, including the ulcerating gastric lesion, is the surgical treatment of choice for most benign gastric ulcers. Whether a Billroth I or Billroth II procedure is used for restoration of gastrointestinal continuity does not seem to have much effect on the results. I personally prefer a Billroth I type of operation when feasible. However, no gastroduodenal anastomosis should be made unless there is a healthy, unscarred, mobile duodenum available for it; and there should never be tension upon the anastomosis. The extent of the resection must be determined to some degree by the location of the
SURGICAL MANAGEMENT OF GASTRIC ULCER
905
ulcer, but resection of more than 50 to 60% of the stomach should be avoided, if possible. In most instances, even with lesions rather high on the lesser curvature, Hofmeister or Schoemaker modifications of the Billroth II or Billroth I operation permit adequate resection of the ulcer with preservation of a very adequate gastric remnant. Recurrences of gastric ulcer after either Billroth I or Billroth II gastric resection are rare. Tanners reported only 2 recurrences after 800 Billroth I resections. Harkins and associates,4 after 140 resections, found only 1 recurrence. Johnson5 had no recurrences in 140 patients who had undergone Billroth II resection. Most competent surgeons can perform such resection with a surgical risk of less than 2%. It is difficult to see how the results of surgical treatment of gastric ulcer can be improved much by procedures other than the classic Billroth I or Billroth II operations and their Schoemaker and Hofmeister modifications. Gastric ulcers high on the lesser curvature, where it approaches the esophagogastric junction, may pose a special problem. Fortunately, not many ulcers develop in this region; and often surgical exploration reveals that they are not actually so high as they may have appeared on radiologic examination. Even these high gastric ulcers can be resected by appropriate tailoring of the lesser-curvature resection, preserving the fundus and the greater curvature for a very adequate gastric reservoir. If the ulcer is so close to the esophagogastric junction that resection cannot be achieved without compromise of this structure, multiple biopsies of the lesion may rule out possible malignancy; and then vagotomy with antrectomy or a gastric drainage procedure may be done. Satisfactory results with healing of the ulcer after this type of management have been reported.
CONCLUSIONS I would emphasize that for ulcerating lesions of the stomach surgical treatment generally is better than medical. In most instances standard distal gastrectomy of either the Billroth I or Billroth II type provides good results at minimal risk.
REFERENCES 1. Angel RT, Giacobine JW, Jordan GL Jr: A current evaluation of the problem of gastric ulcers. Amer J Surg 114:730-735, 1967 2. Capper WM: Factors in the pathogenesis of gastric ulcer. Ann Roy Coll Surg Eng 40:2135,1967 3. Dragstedt LR: A concept of the etiology of gastric and duodenal ulcers. Gastroenterology 30:208-214,1956 4. Harkins HN, Schmitz EJ, Nyhus LM, et al: The Billroth I gastric resection: experimental studies and clinical observations on 291 cases. Ann Surg 140:405-424, 1954 5. Johnson HD: Billroth-I and Polya operations (letter to the editor). Lancet 1:298, 1956. 6. Johnson HD: The pathogenesis of peptic ulcers. Lancet 2:515-517,1957 7. Stemmer EA, Zahn RL, Hom LW, et al: Vagotomy and drainage procedures for gastric ulcer. Arch Surg (Chicago) 96:586-592,1968
906
O. THERON CLAGETT
8. Strauss AA: Longitudinal resection of the lesser curvature with resection of pyloric sphincter for gastric ulcer: an experimental and clinical study. JAMA 82: 1765-1770, 1924 9. Tanner NC: Non-malignant affections of the upper stomach. Ann Roy Coll Surg Eng 10:45-60,1952 10. Walton AJ: Failures of gastric surgery. Lancet 1 :893-897,1934 11. Weinberg JA: Cited by Harkins HN, Nyhus LM: Surgery of the Stomach and Duodenum. Boston, Little, Brown & Company, 1962, p 167 12. Welch CF, Burke JF: An appraisal of the treatment of gastric ulcer. Surgery 44:943958,1958