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The Surgical Treatment of Peptic Ulcer
THE SURGICAL CLINICS of
NORTH AMERICA NATIONWIDE NUMBER ==========~~- ~~ -~
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SYMPOSIUM ON GASTROINTESTINAL SURGERY THE SURGICAL TREATMENT OF PEPTIC ULCER GEORGE CRILE, JR.,
M.D., }'.A.C.S.
GASTRIC ulcer and duodenal ulcer are different diseases which hav(' different consequences and require different treatments. The oversecretion of hydrochloric acid seems to playa more important role in duodenal ulcer than in gastric ulcer; the acidity of the gastric juice may be normal or even low in gastric ulcer. After a gastric resection for gastric ulcer there is little or no tendency for ulceration to occur in the jejunum. Gastric ulcer attacks people of an older age group than those affected by duodenal ulcer. It is often impossible to differentiate between a benign gastric ulcer and an ulcerating carcinoma; in fact, in some instances carcinoma may originate in a benign gastric ulcer. For these reasons the treatment of gastric ulcer is primarily a surgical problem, involving excision of a potential cancer, whereas the treatment of duodenal ulcer is essentially a medical problem and requires operation only when the symptoms are rendered intractable by complications. The results of gastric resection for duodenal ulcer have left much to be desired. If most of the stomach is removed the patients often fail to regain their weight and strength or suffer from sensations of weakness and fullness or distress when they eat (dump syndrome). When less radical resections are performed, and even when most of the stomach is removed, the ulcer recurs at the site of the anastomosis in about 6 per cent of the cases. Moreover, the mortality rate of gastric resection for duodenal ulcer is increased by the difficulties encountered in removing the ulcer and effecting a good closure of the duodenal stump without injuring the common bile duct. The results of gastric resection for gastric ulcer arc excellent. There is
From the Cleveland Clinic, Cleveland, Ohio. 1123
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GEORGE CRILE, JR.
no problem of closing the duod~nal stump, and the later complication of marginal ulcer is exceedingly rare. The resections need not be so radical as in duodenal ulcer unless the ulcer is located very high. Hence the mortality and the morbidity rates are low. High gastric ulcers originating a ceNtimeter 0r two from the esophagus present a different problem. In some cases no less radical a procedure than total gastrectomy can remove the ulcer. In the very high ulcers it is questionable whether this risk of mortality and morbidity is justified when more conservative procedures, such as biopsy of the ulcer coupled with gastroenterostomy or gastroenterostomy and vagotomy, are effective. TREATMENT OF GASTRIC ULCER
Indications for Operation.-Since gastric ulcers cannot always be differentiated from gastric carcinomas by x-ray examination, by gastroscopy, by analysis of clinical data, or even at the time of operation, the treatment is primarily surgical. By this it is not implied that all gastric ulcers should be resected as soon as the diagnosis is made, without a trial of medical therapy, but certainly all large gastric ulcers, all recurrent gastric ulcers, and all gastric ulcers which persist in spite of an adequate trial of a month of medical treatment should be resected unless there are strong contraindicat'ions. The criteria of healing are failure of the roentgenol0gic or gastr@scopic examination to demonstrate an ulcer, complete subsidence of symptoms and disappearance of blood from the stool. Choice of Operation.-Gastric resection is the treatment of choice for the average gastric ul~er occurring in the pylorus, antrum, or pars media of the stomach. Since there is almost no tendency for marginal ulcers to develop after operations for gastric ulcer, there is no need to perform a vagotomy unless the values of free acid are unusually high. When the ulcer is IQcated so high that it could not be resected without removing all or most of the stomach, a satisfactory result can be obtained by vagotomy. It is essential that a biopsy be made to rule out malignancy. This cam be done with a biopsy forceps through a gastroenterostomy stoma, even when the ulcer is high, and by gastrotomy if a gastroenterostomy is not performed. A third procedure well adapted to the treatment of small ulcers is vagotomy, excision of the ulcer and gastroenterostomy. When the ulcer lies 0n the anterior or posterior wall its excision does not disturb the motility of the stomach and it is not necessary to perform a gastroenterostomy. When the ulcer is (!)n the lesser cllrvature:or when it is necessary to remove any part of the lesser curvature, the emptying of the stomach may be delayed and a gastroenterostomy should be performed.
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Vagotomy alone without resection, excision, ®r at least biopsy of a gastric ulcer should not be employed because of the danger that carcinoma might be present.
TREATMENT OF DUODENAL ULCER The subject of the treatment of intractable duodenal ulcer is contr0versial. Some still believe that radical gastric resection is the treatment of choice, whereas others prefer the more conservative procedure of vagotomy combined with pyloroplasty or gastroenterostomy. Our reasons for preferring transabdominal vagotomy, coupled with a conservative operation to afford drainage of the denervated stomach, are based on an experience of only two and one-half years, but since the initial results following vagotomy have been superior to those obtained by any other method of treatment we believe that we are justified in res@rting to this operation when medical treatment proves ineffective. About 85 per cent of the patients. we see with duodenal ulcer make satisfactory progress on medical management. The patients who are being subjected to vagotomy are those with intractable complications (;If duodenal ulcer which require surgical intervention. Since transabdominal vagotomy has proved safer and more effective than gastric resection and since removal of three fourths or more of the stomach is an irreversible procedure which cannot be altered even it it produces incapacitating symptoms, it would appear that vagotomy is the conservative method of treatment and that gastric resection is unnecessarily radical. Duodenal ulcer is a disease which causes much distress but rarely threatens life except in the case of perforation. Since it is not a disease which carries with it a high mortality rate, operations which entail a significant risk and a high morbidity are not justified in its treatment. In spite of the fact that in the past ten years at the Cleveland Clinic the mortality rate of gastric resection for duodenal ulcer has been only 2.8 per cent, we have felt that any mortality incurred in the treatment of a disease which does not directly threaten the life of the patient is an irreparable tragedy. We therefore welcomed transabdominal vagotomy as a procedure which entails a minimal risk and which, over a period of more than two years in our hands and of five years in the experience of Dr. Lester Dragstedt, has afforded the best protection against recurrence of ulcer. Transabdominal vagotomy has now been performed by Dr. T. E. Jones and myself 228 times with four deaths. One patient died as a result of perforation of the ulcer, which occurred three days after operution. One obese patient died on the fourth postoperative day, and autopsy revealed no cause for death; examination of the brain was not permitted.
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GEORGE CRILE, JR.
One patient who was obese and whose esophagus was isolated to aid in identification of the nerves died of mediastinitis from perforation of the esophagus. The mortality rate of vagotomy in 227 consecutive cases is thus 1.3 per cent. A fourth death has occurred in the hospital after vagotomy, but it hardly seems fair to attribute it to the operation. The patient was exsanguinated and pulseless at the time of operation. The bleeding point was ligated and the vagus nerves resected. Convalescence was uneventful, and the patient was dressed and on the point of going home when he developed chills and fever. Following this he had another massive hemorrhage from the ulcer. A second operation was performed, the bleeding point was again ligated, the duodenum was excluded by infolding the pylorus, and a gastroenterostomy was done. The patient expired several days after the second operation. Autopsy showed both lungs to be consolidated in what appeared to be an extensive virus pneumonia. If this death, occurring in a patient subjected to an emergency operation, is included, the mortality rate is 1.8 per cent. Dragstedt has performed approximately 300 transabdominal vagotomies with "no deaths attributable to the procedure."l Most of the reported complications and deaths have followed transthoracic vagotomy, an operation which we have now abandoned because the stomach can nearly always be denervated as well by the transabdominal approach. It is true that our period of observation has been too short to permit final evaluation of the method. Nevertheless, it is already apparent to us that in the first two and one-half years after operation, vagotomy accompanied by gastroentcrostomy or pyloroplasty is (1) safer than gastric resection, (2) more effective than gastric resection in controlling recurrent ulceration, and (3) preferable to gastric resection because its morbidity is lower and it is more effective in restoring the patient to health and normal activity.2 The gratifying initial results obtained in our first 50 vagotomies for peptic ulcer (gastric, jejunal and duodenal) have been reported by Collins and Stevenson. 3 As time passes these results become even more gratifying. There have been no late recurrences of symptoms due to ulcer. Comparison of Results of Vagotomy with Other Methods of Treatment.-The course of fifty consecutive patients during the first year following gastric resection for duodenal ulcer has been analyzed and compared with that of fifty consecutive patients subjected to vagotomy alone or combined with gastroenterostomy or pyloroplasty (Table 1). Complications which occurred over a year after resection were disregarded so that the time interval of the studies would be comparable. All patients . were followed for at least four months. The results were graded as follows;
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SURGICAL TREATMENT OF PEPTIC ULCER
Excellent-no signi£cant gastrointestinal symptoms; patient well and working. Improved-persistent gastrointestinal symptoms requiring intermittent or constant dietary and medical treatment. Failure-uncontrollable symptoms as severe as before operation. Three of the six patients classified as failures following gastric resection developed demonstrable jejunal ulcers in the first year. The other three developed symptoms typical of jejunal ulcer, but the ulcer could not be demonstrated. TABLE 1 COlY.PARIHOK O~' RESULTS OF OPERATIOK
Followed Survivors Kot Fol- - - I Ity lowen ExcelIm- I F '1 ! c~ne:) (per, lent proved I (~~;e cent) ! (per (per t) _ _ _ _ ! _ _ _ _ I cent) ~_~_ i
Mortal-
I
I[
·
Gastric resection-50 cases. Gastroenterostomy-50 cases. Vagotomy-50 cases...... . . . . . . . . (13 had vagotomies only, 30 had gastroenterostomies, 7 had pyloroplasties)
4*
ot
6
5H
'29
13
10
53
33
14
o
88
10
'l
* In the larger group of 140 cases the murtality was 'l.8 per cent. t In the lal'l:,er group of 228 cases the mortality was 1.3 per cent. The patient who is classified as a failure following vagotomy was subjected to vagotomy alone without any complementary operation to facilitate emptying of the denervated stomach. Three months later, because of persistent symptoms referable to gastric retention, a gastroenterostomy was performed. The complaints of the thirteen patients who continued to have symptoms after gastric resection alone but who were classified as improved were as follows: Two had pain similar to preoperative pain. Two had pain, vomited, and were losing weight. Two vomited after meals. Two had persistent nausea. One had vague gastrointestinal symptoms and subsequently died of appendicitis. One had a hemorrhage from the stomach and suffered from bloating.
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GEORGE CRILE, .JR.
One had pain and a hemorrhage. One had a bad taste in mouth and poor appetite. One was weak and did not gain weight. The complaints of the five patients who continue to have symptoms after vagotomy but who are classified as improved are as follows: Two have diarrhea and bloating after meals but are improving steadily four months after operation. One has gas, belching and mild diarrhea but considers his condition much better than before operation. One has nausea, weakness and intermittent diarrhea. One experiences persistent ulcer-like symptoms, although no ulcer can be demonstrated by roentgenogram. This patient had a very small posterior vagus trunk, and it is probable that the denervation was incomplete. The symptoms are controlled by medical management. Three of the six patients who failed to obtain excellent results were subjected to vagotomy alone, without pyloroplasty or gastroenterostomy. These patients developed symptoms referable to gastric retention, but they are improving with the passing of time. In none of these except the one who required a secondary gastroenterostomy has the retention incapacitated the patient or proved to be more than an inconvenience and embarrassment. Nevertheless, my personal preference is for the routine employment of pyloroplasty or gastroenterostomy, the choice of operation depending on the amount of fixation and scarring of the duodenum. None of the patients in this series has taken antacids or followed a diet other than the bland diet prescribed for the first six weeks after operation. Smoking and alcohol have not been interdicted. This is in sharp contrast to the management of patients subjected to gastric resection, most of whom were advised to maintain a full medical regimen of antacids and diet and to eliminate tobacco and alcohol. In addition to the five patients who have symptoms of sufficient significance to warrant treatment, there are eleven others (22 per cent) who have symptoms so mild that they do not require treatment, do not interfere with normal activities, and are elicited only in response to the promptings of a questionnaire. On the basis of the patient's own evaluation and of the patient's ability to return to normal activity without medical management, the results in these cases have been classified as excellent. Four have occasional gas pains. Two are constipated (one has a feeling of fullness when bowels do not move, the other a slight gas pain).
SURGICAL '1'REATMENT OF PEPTIC ULCER
One has One has day). One has One has One has
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occasional diarrhea. stools which are watery but not frequent (only one or two a occasional belching of foul gas. occasional pain on right side. diarrhea and gas pain after eating fresh fruit.
Since the majority of patients who develop marginal ulcers have symptoms or demonstrable ulcers in the first year after operation,4 these figures, although admittedly covering only a brief period, probably are significant. In any case, they indicate that the mortality and morbidity in the first year after vagotomy, alone in selected cases or more often in conjunction with pyloroplasty or gastroenterostomy, is much lower than that following gastric resection. The results following gastroenterostomy alone have been as unsatisfactory as are those following resection. The incidenc~ of marginal ulcer and of persistent symptoms requiring medical treatment in a series of fifty consecutive cases was higher in the first year than was observed in patients subjected to gastric resection. It is clear, therefore, that the gastroenterostomies and pyloroplasties that were commonly performed in conjunction with a vagotomy cannot be given too much credit for the results obtained in this series of cases. Even those who most strongly oppose the use of vagotomy in the treatment of peptic ulcer do so because they fear that vagotomy will not afford permanent protection against recurrent ulceration rather than because they fear the end results of sectioning of the vagus nerve. 5 They combine vagotomy with gastric resection in the treatment of duodenal ulcer and in so doing accept the additional hazard of resection. This is in spite of the experience of Dragstedt, who has performed vagotomy alone or with gastroenterostomy and has followed his patients for four years or more without observing recurrences in patients whose stomachs have been completely denervated. Since it appears that the mortality rate of gastroenterostomy and vagotomy will be lower than that of resection in the hands of the same surgeon, the burden of proof rests upon him who accepts the resp(!)llsibility of employing an operation which entails a greater risk and whose immediate results arc not so satisfactory as are those which follow the safer procedure. And always, regardless of the apparent safety of transabdominal vagotomy, it should be emphasized that any operation entails risk, that duodenal ulcer is rarely a fatal disease, and that the risk of even so safe a procedure as vagotomy should not be undertaken until a fair trial has been given to medical treatment.
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GEORGE CRILE, JR.
JEJUNAL ULCER
If no obstruction is demonstrable by x-ray examination, transabdominal vagotomy is the preferred treatment for jejunal ulcer. If obstruction is present a vagotomy should be performed, the old gastroenterostomy taken down and a new one made. The results in a series of seventeen cases treated in this manner have been excellent, and there have been no recurrences of symptoms. The patients have been followed from one to twenty-eight months after operation. TECHNIC OF VAGOTOMY
Transabdominal vs. Transthoracic Vagotomy.-Transabdominal vagotomy has supplanted the transthoracic approach because (1) the abdominal approach allows examination of the ulcer and concomitant abdominal disease, such as gallstones; (~) the abdominal approach enables the surgeon simultaneously to perform some type of operation such as gastroenterostomy or pyloroplasty so that the hypomotility resulting from vagotomy will not result in gastric retention; (8) the abdominal approach is probably safer than the transthoracic; (4) the scar left by the abdominal incision is less troublesome than the intercostal, where neuralgia sometimes follows resection of a rib; (5) anatomic studies have shown that subdiaphragmatic vagotomy usually can be as complete and effective as transthoracic; (6) the results of subdiaphragmatic vagotomy, as indicated by the clinical course of the patients, are comparable to those following the transthoracic approach. Surgical Anatomy of the Vagus.-Anatomic studies of the vagus indicate that in the majority of cases the vagi form two large trunks above the diaphragm and descend through the esophageal hiatus in the form of two large nerves. Sometimes the main trunks are formed at or even below the level of the diaphragm, and sometimes one or two small branches are given off above the diaphragm and descend through the hiatus with the main trunks. The anterior or left vagus is usually the smaller of the two and is about the size of the lead of a lead pencil. The posterior, or right vagus, is often one and one-half to two times as large. The anterior vagus lies just below the peritoneum near the midline of the esophagus. The posterior vagus has a more variable position but usually lies behind the middle of the esophagus or slightly to the right. Its relationship to the wall of the esophagus is not so intimate as that of the anterior vagus, and it lies in the loose areolar tissue of the posterior abdominal wall more often than in or on the musculature of the esophagus. Sometimes there are several small branches of the vagus given off at about the level of the diaphragm, but usually the nerves do not give off significant branches until they fan out on the wall of the stomach.
SURGICAL TREATMENT OF PEPTIC ULCER
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Preparation for Operation.-Either general anesthesia or a high spinal anesthetic supplemented by pentothal may be used. The stomach should be emptied by gastric suction and a Levine tube left in place to aid in identifying the esophagus. Expo8ure.-A midline incision is not only less vascular and easier to open and close than a left rectus incision, but it also affords a higher and hence a better exposure. It extends from the umbilicus to the xiphoid (Fig. 316).
FIG. 316.-Midline incision xiphoid to umbilicus.
Before proceeding with vagotomy the abdomen should be explored, and the surgeon should examine the stomach, duodenum, gallbladder and esophageal hiatus. It is unwise to perform a gastric operation before vagotomy because soiling from the gastric operation results in contamination of the vulnerable mediastinum and subdiaphragmatic space during the vagotomy. Moreover, if for some reason a satisfactory vagotomy cannot be accomplished, it is possible that the surgeon would elect a radical rather than a conservative gastric operation. The left lobe of the liver does not interfere with exposure of the vagus.
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GE;ORW'; CHILE, JR.
In several of the earlier cases it seemed desirable to divide the avascular diaphragmatic attachments of the left lobe of the liver and reflect it to the,right to obtain better exposure of the diaphragm. With increasing experience this maneuver has not been necessary. A broad Deaver or malleable retractor inserted under the liver to lift it forward affords adequate exposure.
FIG. 317.-Locating anterior vagus nerve. Stomach is pulled downward, stretching elastic tissues of peritoneum and esophagus. Vagus is not elastic, becomes taut as a violin string, is easily palpable. Peritoneum is incised, and nerve is picked up on a nerve hook.
Identification of the Vagus.-The anterior vagus is quite constant in its location and usually can be found with little or no difficulty. The surgeon stands on the right side of the table. The stomach is grasped in the right hand with a moist tape and retracted downward, while an assistant retracts the liver anteriorly with a Deaver retractor to expose the lower part of the esophagus. By palpation with the left hand the operator can identify the Levine tube in the esophagus. Firm downward traction is then exerted on the stomach in such a way that the esophagus is stretched. The musculature of the esophagus, the peritoneum reflecting
SURGICAL TREATMENT OF PEPTIC ULCER
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from the stomach and the esophagus on to thc diaphragm, and the blood vessels of the stomach and esophagus are elastic, whereas the vagus nerve is nonelastic and stands out like a violin string, palpable and often visible beneath the peritoneum. As soon as the nerve is identified by palpation with index finger of the left hand, the traction on the stomach is delegated to an assistant who maintains it while the peritoneum overlying the nerve is incised and the nerve is picked up on a long nerve hook.
FIG. gI8.-Stripping vagus nerve. A wire loop is placed over vagus and is thrust upward into mediastinum lo strip small fibers from main trunk.
Its identity is quite unmistakable, and as soon as it is isolated it can be proved to be the vagus by following it upward through the esophageal hiatus in the diaphragm. The blood vessels of the stomach do not course in this direction nor does the esophageal hiatus transmit any other structure from the thorax to the abdomen (Fig. 317). The nerve is isolated by blunt dissection with a special instrument which is passed through the diaphragm and preferably higher so that there will be no question of failure to remove all accessible branches (Fig. 318). The nerve is then clamped with a Moynihan clamp, divided,
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GEORGE CRILE, JR.
and again divided several centimeters lower. The excised segment 2 to 5 cm. in length is examined by the pathologist to prove its identity.
Mter completion of the anterior vagotomy the forefinger of the left hand is inserted through the delicate peritoneum of the gastrohepatic omentum above the gastric vessels, as in mobilization of the stomach for total gastrectomy. The stomach is again pulled downward by the right hand, and the posterior vagus is located by palpation as a tense cord
FIG. 319.-Locating posterior vagus nerve. Posterior vagus usually lies behind and to the right of esophagus, is often well away from esophagus. Downward traction is exerted on stomach, and posterior vagus is located by palpation.
lying posterior to the esophagus in the areolar tissue. Occasionally it appears to be more to the right of the esophagus than directly posterior and may be surprisingly far away from it. While an assistant pulls the stomach and esophagus downward anteriorly and to the left, the nerve which is identified by the index finger of the left hand is picked up by a nerve hook and is dissected out, as in the case of the anterior nerve. It is important to make certain that it passes upward through the esophageal hiatus since there are vessels posteriorly that could be confused with the vagus if its course through the hiatus is not checked. Mter denervation
StIRGlCAL TREATMENT OF PEPTIC ULCER
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of its branches a segment of the nerve is removed, as in the anterior vagotomy (Fig. 319). A final examination of the esophagus should be made to exclude the presence of additional branches coming down from above the diaphragm. It is not necessary to reconstruct the peritoneum. Attention is next directed to whatever operation on the stomach is desirable to prevent gastric retention. Pyloroplasty, gastric resection; gastroenterostomy and local excision of the ulcer each has its place, and the selection must depend on the size of the ulcer, its location, the amount of obstruction, the completeness of the vagotomy and on the preferences
FIG. 3£O.-Technic of pyloroplasty. After completion of vagotomy either a pyloroplasty or a gastroenterostomy is performed in order to facilitate emptying of the denervated stomach.
of the surgeon. Whenever feasible, pyloroplasty would appear to be the operation of choice because of its simplicity, because it entails no disturbance of normal mechanical or physiologic processes, and also because, if ulceration should recur, gastric resection could be performed with ease and without the difficulty involved in taking down a gastroenterostomy. But there are many cases in which the duodenum is fixed and foreshortened, in which pyloroplasty is not easily accomplished and gastroenterostomy is preferable. In about 50 per cent of the cases, however, a simple longitudinal incision through the pyloric muscle and the narrowest portion of the duodenum can be sutured transversely with correction of any tendency to obstruction (Fig. 3!l0). Before the pylorus
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GEORGE CRILE, JR.
is closed a finger should be inserted first into the duodenum and then into the stomach to make certain that there is no stenosis not corrected by pyloroplasty. Postoperative Course.-In addition to the safety of the procedure the immediate convalescence of the patient is smoother and more comfortable than that of any comparable group of patients with ulcer treated by gastric resection alone. Unpleasant complications such as vomiting from gastric retention and distress or a feeling of fullness after meals (the so-called "dump syndrome") have rarely occurred following vagotomy and pyloroplasty or gastroenterostomy: gastrojejunal ulceration has not been observed. The pain is relieved from the time of operation, and the appetite is good. The patients are out of bed on the first or second postoperative day. Usually by the eighth day they are eating a liberal diet, are free of symptoms and are able to go home. Gastric suction is maintained for one to four days until it is apparent that the stomach is emptying satisfactorily. In this way overdistention is avoided. Even if a gastroenterostomy or pyloroplasty has been done there may be some gastric retention, although the symptoms associated with the retention are minimal and soon subside. If vagotomy is not accompanied by some operation to drain the denervated stomach, retention is commonly observed, even if there was no demonstrable obstruction at the time of the operation. COMPLICATIONS OF VAGOTOMY
In the majority of cases vagotomy is easily accomplished and does not unduly prolong the operating time. Occasionally in obese patients or when exposure is poor, identification of the nerves is facilitated by slipping a Penrose drain or tape around the esophagus and drawing it downward. I have rarely found this maneuver necessary, and in one patient weighing 232 pounds and having a large left lobe of the liver and a high diaphragm, isolation of the esophagus proved to be dangerous. I had inserted my finger through the gastrohepatic omentum and was gently finger-dissecting around the totally unexposable esophagus when I suddenly found that I was lower than I had thought and had inserted my finger through the posterior wall of the stomach, where I could palpate the Levine tube. The proposed vagotomy was abandoned, and the small hole in the stomach was closed over as well as possible with fat. Two Levine tubes were left in the stomach with constant suction, and a pyloroplasty was performed. The patient was kept in Fowler's position wit1l the tubes in place for four days and made an uneventful convalescence. The symptoms of ulcer recurred in four weeks. This case, in which a gastric resection would have been difficult and
SURGICAL TREATMENT OF PEPTIC ULCER
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in which the patient was a poor surgical risk, was the only instance in which technical difficulties have arisen during vagotomy and the only one in which a proposed vagotomy was not completed. In several cases no large posterior vagus trunks could be located, but several small nerves were found and divided. Occasionally there are as many as five or six nerves instead of the usual main trunks. Only once was a blood vessel cut by mistake, and in this case the bleeding was easily controlled. Insulin tolerance tests have not been made following operation because pyloroplasty or gastroenterostomy causes a regurgitation of bile into the stomach and invalidates the test. SUMMARY 1. After two and one-half years of experience with transabdominal vagotomy coupled with pyloroplasty or gastroenterostomy for duodenal ulcer, we believe it to be (a) safer than gastric resection, (b) more effective than gastric resection in controlling the tendency to recurrent ulceration, and (c) attended by lesser morbidity and disability than is gastric resection. 2. The results obtained with vagotomy and gastroenterostomy or pyloroplasty justify this procedure as the treatment of choice when surgical intervention is indicated for duodenal ulcer. 3. Duodenal ulcer is primarily a medical problem, and operation should not be advised until medical management has been given a fair trial. 4. Most cases of gastric ulcer requiring operation should be treated by gastric resection rather than by vagotomy. 5. Vagotomy for gastric ulcer is not recommended unless (a) the ulcer is excised and examined microscopically, or (b) the ulcer is so high that it cannot be resected without performing a total gastrectomy or incurring undue risk. 6. Transabdominal vagotomy is the preferred treatment for gastrojejunal ulcer.
REFERENCES 1. Dragstedt, L. R.: Personal communication. 2. Crile, G., Jr.: Transabdominal Vagotomy versus Gastric Resection in Treatment of Duodenal Ulcer. Cleveland Clin. Quart. 14:264-270 (Oct.) 1947. 3. Collins, E. N. and Stevenson, C. W.: Bilateral Vagotomy in Treatment of Peptic Ulcer. Gastroenterology 10:205-215 (Feb.) 1948. 4. Renshaw, R. J. F. and (by invitation) Beck, R. H.: Peptic Ulcer; Evaluation of Surgical Treatment. Proc. Am. Federation Clin. Research 3:85-86 (April 28) 1947. 5. Editorial: Conservative Approach to Vagotomy. J. A. M. A. 134:786 (June 28) 1947.
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SYMPOSIUM ON GASTROINTESTINAL SURGERY THE SURGICAL TREATMENT OF PEPTIC ULCER GEORGE CRILE, JR.,
M.D., }'.A.C.S.
GASTRIC ulcer and duodenal ulcer are different diseases which hav(' different consequences and require different treatments. The oversecretion of hydrochloric acid seems to playa more important role in duodenal ulcer than in gastric ulcer; the acidity of the gastric juice may be normal or even low in gastric ulcer. After a gastric resection for gastric ulcer there is little or no tendency for ulceration to occur in the jejunum. Gastric ulcer attacks people of an older age group than those affected by duodenal ulcer. It is often impossible to differentiate between a benign gastric ulcer and an ulcerating carcinoma; in fact, in some instances carcinoma may originate in a benign gastric ulcer. For these reasons the treatment of gastric ulcer is primarily a surgical problem, involving excision of a potential cancer, whereas the treatment of duodenal ulcer is essentially a medical problem and requires operation only when the symptoms are rendered intractable by complications. The results of gastric resection for duodenal ulcer have left much to be desired. If most of the stomach is removed the patients often fail to regain their weight and strength or suffer from sensations of weakness and fullness or distress when they eat (dump syndrome). When less radical resections are performed, and even when most of the stomach is removed, the ulcer recurs at the site of the anastomosis in about 6 per cent of the cases. Moreover, the mortality rate of gastric resection for duodenal ulcer is increased by the difficulties encountered in removing the ulcer and effecting a good closure of the duodenal stump without injuring the common bile duct. The results of gastric resection for gastric ulcer arc excellent. There is
From the Cleveland Clinic, Cleveland, Ohio. 1123
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GEORGE CRILE, JR.
no problem of closing the duod~nal stump, and the later complication of marginal ulcer is exceedingly rare. The resections need not be so radical as in duodenal ulcer unless the ulcer is located very high. Hence the mortality and the morbidity rates are low. High gastric ulcers originating a ceNtimeter 0r two from the esophagus present a different problem. In some cases no less radical a procedure than total gastrectomy can remove the ulcer. In the very high ulcers it is questionable whether this risk of mortality and morbidity is justified when more conservative procedures, such as biopsy of the ulcer coupled with gastroenterostomy or gastroenterostomy and vagotomy, are effective. TREATMENT OF GASTRIC ULCER
Indications for Operation.-Since gastric ulcers cannot always be differentiated from gastric carcinomas by x-ray examination, by gastroscopy, by analysis of clinical data, or even at the time of operation, the treatment is primarily surgical. By this it is not implied that all gastric ulcers should be resected as soon as the diagnosis is made, without a trial of medical therapy, but certainly all large gastric ulcers, all recurrent gastric ulcers, and all gastric ulcers which persist in spite of an adequate trial of a month of medical treatment should be resected unless there are strong contraindicat'ions. The criteria of healing are failure of the roentgenol0gic or gastr@scopic examination to demonstrate an ulcer, complete subsidence of symptoms and disappearance of blood from the stool. Choice of Operation.-Gastric resection is the treatment of choice for the average gastric ul~er occurring in the pylorus, antrum, or pars media of the stomach. Since there is almost no tendency for marginal ulcers to develop after operations for gastric ulcer, there is no need to perform a vagotomy unless the values of free acid are unusually high. When the ulcer is IQcated so high that it could not be resected without removing all or most of the stomach, a satisfactory result can be obtained by vagotomy. It is essential that a biopsy be made to rule out malignancy. This cam be done with a biopsy forceps through a gastroenterostomy stoma, even when the ulcer is high, and by gastrotomy if a gastroenterostomy is not performed. A third procedure well adapted to the treatment of small ulcers is vagotomy, excision of the ulcer and gastroenterostomy. When the ulcer lies 0n the anterior or posterior wall its excision does not disturb the motility of the stomach and it is not necessary to perform a gastroenterostomy. When the ulcer is (!)n the lesser cllrvature:or when it is necessary to remove any part of the lesser curvature, the emptying of the stomach may be delayed and a gastroenterostomy should be performed.
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1125
Vagotomy alone without resection, excision, ®r at least biopsy of a gastric ulcer should not be employed because of the danger that carcinoma might be present.
TREATMENT OF DUODENAL ULCER The subject of the treatment of intractable duodenal ulcer is contr0versial. Some still believe that radical gastric resection is the treatment of choice, whereas others prefer the more conservative procedure of vagotomy combined with pyloroplasty or gastroenterostomy. Our reasons for preferring transabdominal vagotomy, coupled with a conservative operation to afford drainage of the denervated stomach, are based on an experience of only two and one-half years, but since the initial results following vagotomy have been superior to those obtained by any other method of treatment we believe that we are justified in res@rting to this operation when medical treatment proves ineffective. About 85 per cent of the patients. we see with duodenal ulcer make satisfactory progress on medical management. The patients who are being subjected to vagotomy are those with intractable complications (;If duodenal ulcer which require surgical intervention. Since transabdominal vagotomy has proved safer and more effective than gastric resection and since removal of three fourths or more of the stomach is an irreversible procedure which cannot be altered even it it produces incapacitating symptoms, it would appear that vagotomy is the conservative method of treatment and that gastric resection is unnecessarily radical. Duodenal ulcer is a disease which causes much distress but rarely threatens life except in the case of perforation. Since it is not a disease which carries with it a high mortality rate, operations which entail a significant risk and a high morbidity are not justified in its treatment. In spite of the fact that in the past ten years at the Cleveland Clinic the mortality rate of gastric resection for duodenal ulcer has been only 2.8 per cent, we have felt that any mortality incurred in the treatment of a disease which does not directly threaten the life of the patient is an irreparable tragedy. We therefore welcomed transabdominal vagotomy as a procedure which entails a minimal risk and which, over a period of more than two years in our hands and of five years in the experience of Dr. Lester Dragstedt, has afforded the best protection against recurrence of ulcer. Transabdominal vagotomy has now been performed by Dr. T. E. Jones and myself 228 times with four deaths. One patient died as a result of perforation of the ulcer, which occurred three days after operution. One obese patient died on the fourth postoperative day, and autopsy revealed no cause for death; examination of the brain was not permitted.
1126
GEORGE CRILE, JR.
One patient who was obese and whose esophagus was isolated to aid in identification of the nerves died of mediastinitis from perforation of the esophagus. The mortality rate of vagotomy in 227 consecutive cases is thus 1.3 per cent. A fourth death has occurred in the hospital after vagotomy, but it hardly seems fair to attribute it to the operation. The patient was exsanguinated and pulseless at the time of operation. The bleeding point was ligated and the vagus nerves resected. Convalescence was uneventful, and the patient was dressed and on the point of going home when he developed chills and fever. Following this he had another massive hemorrhage from the ulcer. A second operation was performed, the bleeding point was again ligated, the duodenum was excluded by infolding the pylorus, and a gastroenterostomy was done. The patient expired several days after the second operation. Autopsy showed both lungs to be consolidated in what appeared to be an extensive virus pneumonia. If this death, occurring in a patient subjected to an emergency operation, is included, the mortality rate is 1.8 per cent. Dragstedt has performed approximately 300 transabdominal vagotomies with "no deaths attributable to the procedure."l Most of the reported complications and deaths have followed transthoracic vagotomy, an operation which we have now abandoned because the stomach can nearly always be denervated as well by the transabdominal approach. It is true that our period of observation has been too short to permit final evaluation of the method. Nevertheless, it is already apparent to us that in the first two and one-half years after operation, vagotomy accompanied by gastroentcrostomy or pyloroplasty is (1) safer than gastric resection, (2) more effective than gastric resection in controlling recurrent ulceration, and (3) preferable to gastric resection because its morbidity is lower and it is more effective in restoring the patient to health and normal activity.2 The gratifying initial results obtained in our first 50 vagotomies for peptic ulcer (gastric, jejunal and duodenal) have been reported by Collins and Stevenson. 3 As time passes these results become even more gratifying. There have been no late recurrences of symptoms due to ulcer. Comparison of Results of Vagotomy with Other Methods of Treatment.-The course of fifty consecutive patients during the first year following gastric resection for duodenal ulcer has been analyzed and compared with that of fifty consecutive patients subjected to vagotomy alone or combined with gastroenterostomy or pyloroplasty (Table 1). Complications which occurred over a year after resection were disregarded so that the time interval of the studies would be comparable. All patients . were followed for at least four months. The results were graded as follows;
1127
SURGICAL TREATMENT OF PEPTIC ULCER
Excellent-no signi£cant gastrointestinal symptoms; patient well and working. Improved-persistent gastrointestinal symptoms requiring intermittent or constant dietary and medical treatment. Failure-uncontrollable symptoms as severe as before operation. Three of the six patients classified as failures following gastric resection developed demonstrable jejunal ulcers in the first year. The other three developed symptoms typical of jejunal ulcer, but the ulcer could not be demonstrated. TABLE 1 COlY.PARIHOK O~' RESULTS OF OPERATIOK
Followed Survivors Kot Fol- - - I Ity lowen ExcelIm- I F '1 ! c~ne:) (per, lent proved I (~~;e cent) ! (per (per t) _ _ _ _ ! _ _ _ _ I cent) ~_~_ i
Mortal-
I
I[
·
Gastric resection-50 cases. Gastroenterostomy-50 cases. Vagotomy-50 cases...... . . . . . . . . (13 had vagotomies only, 30 had gastroenterostomies, 7 had pyloroplasties)
4*
ot
6
5H
'29
13
10
53
33
14
o
88
10
'l
* In the larger group of 140 cases the murtality was 'l.8 per cent. t In the lal'l:,er group of 228 cases the mortality was 1.3 per cent. The patient who is classified as a failure following vagotomy was subjected to vagotomy alone without any complementary operation to facilitate emptying of the denervated stomach. Three months later, because of persistent symptoms referable to gastric retention, a gastroenterostomy was performed. The complaints of the thirteen patients who continued to have symptoms after gastric resection alone but who were classified as improved were as follows: Two had pain similar to preoperative pain. Two had pain, vomited, and were losing weight. Two vomited after meals. Two had persistent nausea. One had vague gastrointestinal symptoms and subsequently died of appendicitis. One had a hemorrhage from the stomach and suffered from bloating.
1128
GEORGE CRILE, .JR.
One had pain and a hemorrhage. One had a bad taste in mouth and poor appetite. One was weak and did not gain weight. The complaints of the five patients who continue to have symptoms after vagotomy but who are classified as improved are as follows: Two have diarrhea and bloating after meals but are improving steadily four months after operation. One has gas, belching and mild diarrhea but considers his condition much better than before operation. One has nausea, weakness and intermittent diarrhea. One experiences persistent ulcer-like symptoms, although no ulcer can be demonstrated by roentgenogram. This patient had a very small posterior vagus trunk, and it is probable that the denervation was incomplete. The symptoms are controlled by medical management. Three of the six patients who failed to obtain excellent results were subjected to vagotomy alone, without pyloroplasty or gastroenterostomy. These patients developed symptoms referable to gastric retention, but they are improving with the passing of time. In none of these except the one who required a secondary gastroenterostomy has the retention incapacitated the patient or proved to be more than an inconvenience and embarrassment. Nevertheless, my personal preference is for the routine employment of pyloroplasty or gastroenterostomy, the choice of operation depending on the amount of fixation and scarring of the duodenum. None of the patients in this series has taken antacids or followed a diet other than the bland diet prescribed for the first six weeks after operation. Smoking and alcohol have not been interdicted. This is in sharp contrast to the management of patients subjected to gastric resection, most of whom were advised to maintain a full medical regimen of antacids and diet and to eliminate tobacco and alcohol. In addition to the five patients who have symptoms of sufficient significance to warrant treatment, there are eleven others (22 per cent) who have symptoms so mild that they do not require treatment, do not interfere with normal activities, and are elicited only in response to the promptings of a questionnaire. On the basis of the patient's own evaluation and of the patient's ability to return to normal activity without medical management, the results in these cases have been classified as excellent. Four have occasional gas pains. Two are constipated (one has a feeling of fullness when bowels do not move, the other a slight gas pain).
SURGICAL '1'REATMENT OF PEPTIC ULCER
One has One has day). One has One has One has
1129
occasional diarrhea. stools which are watery but not frequent (only one or two a occasional belching of foul gas. occasional pain on right side. diarrhea and gas pain after eating fresh fruit.
Since the majority of patients who develop marginal ulcers have symptoms or demonstrable ulcers in the first year after operation,4 these figures, although admittedly covering only a brief period, probably are significant. In any case, they indicate that the mortality and morbidity in the first year after vagotomy, alone in selected cases or more often in conjunction with pyloroplasty or gastroenterostomy, is much lower than that following gastric resection. The results following gastroenterostomy alone have been as unsatisfactory as are those following resection. The incidenc~ of marginal ulcer and of persistent symptoms requiring medical treatment in a series of fifty consecutive cases was higher in the first year than was observed in patients subjected to gastric resection. It is clear, therefore, that the gastroenterostomies and pyloroplasties that were commonly performed in conjunction with a vagotomy cannot be given too much credit for the results obtained in this series of cases. Even those who most strongly oppose the use of vagotomy in the treatment of peptic ulcer do so because they fear that vagotomy will not afford permanent protection against recurrent ulceration rather than because they fear the end results of sectioning of the vagus nerve. 5 They combine vagotomy with gastric resection in the treatment of duodenal ulcer and in so doing accept the additional hazard of resection. This is in spite of the experience of Dragstedt, who has performed vagotomy alone or with gastroenterostomy and has followed his patients for four years or more without observing recurrences in patients whose stomachs have been completely denervated. Since it appears that the mortality rate of gastroenterostomy and vagotomy will be lower than that of resection in the hands of the same surgeon, the burden of proof rests upon him who accepts the resp(!)llsibility of employing an operation which entails a greater risk and whose immediate results arc not so satisfactory as are those which follow the safer procedure. And always, regardless of the apparent safety of transabdominal vagotomy, it should be emphasized that any operation entails risk, that duodenal ulcer is rarely a fatal disease, and that the risk of even so safe a procedure as vagotomy should not be undertaken until a fair trial has been given to medical treatment.
1180
GEORGE CRILE, JR.
JEJUNAL ULCER
If no obstruction is demonstrable by x-ray examination, transabdominal vagotomy is the preferred treatment for jejunal ulcer. If obstruction is present a vagotomy should be performed, the old gastroenterostomy taken down and a new one made. The results in a series of seventeen cases treated in this manner have been excellent, and there have been no recurrences of symptoms. The patients have been followed from one to twenty-eight months after operation. TECHNIC OF VAGOTOMY
Transabdominal vs. Transthoracic Vagotomy.-Transabdominal vagotomy has supplanted the transthoracic approach because (1) the abdominal approach allows examination of the ulcer and concomitant abdominal disease, such as gallstones; (~) the abdominal approach enables the surgeon simultaneously to perform some type of operation such as gastroenterostomy or pyloroplasty so that the hypomotility resulting from vagotomy will not result in gastric retention; (8) the abdominal approach is probably safer than the transthoracic; (4) the scar left by the abdominal incision is less troublesome than the intercostal, where neuralgia sometimes follows resection of a rib; (5) anatomic studies have shown that subdiaphragmatic vagotomy usually can be as complete and effective as transthoracic; (6) the results of subdiaphragmatic vagotomy, as indicated by the clinical course of the patients, are comparable to those following the transthoracic approach. Surgical Anatomy of the Vagus.-Anatomic studies of the vagus indicate that in the majority of cases the vagi form two large trunks above the diaphragm and descend through the esophageal hiatus in the form of two large nerves. Sometimes the main trunks are formed at or even below the level of the diaphragm, and sometimes one or two small branches are given off above the diaphragm and descend through the hiatus with the main trunks. The anterior or left vagus is usually the smaller of the two and is about the size of the lead of a lead pencil. The posterior, or right vagus, is often one and one-half to two times as large. The anterior vagus lies just below the peritoneum near the midline of the esophagus. The posterior vagus has a more variable position but usually lies behind the middle of the esophagus or slightly to the right. Its relationship to the wall of the esophagus is not so intimate as that of the anterior vagus, and it lies in the loose areolar tissue of the posterior abdominal wall more often than in or on the musculature of the esophagus. Sometimes there are several small branches of the vagus given off at about the level of the diaphragm, but usually the nerves do not give off significant branches until they fan out on the wall of the stomach.
SURGICAL TREATMENT OF PEPTIC ULCER
1131
Preparation for Operation.-Either general anesthesia or a high spinal anesthetic supplemented by pentothal may be used. The stomach should be emptied by gastric suction and a Levine tube left in place to aid in identifying the esophagus. Expo8ure.-A midline incision is not only less vascular and easier to open and close than a left rectus incision, but it also affords a higher and hence a better exposure. It extends from the umbilicus to the xiphoid (Fig. 316).
FIG. 316.-Midline incision xiphoid to umbilicus.
Before proceeding with vagotomy the abdomen should be explored, and the surgeon should examine the stomach, duodenum, gallbladder and esophageal hiatus. It is unwise to perform a gastric operation before vagotomy because soiling from the gastric operation results in contamination of the vulnerable mediastinum and subdiaphragmatic space during the vagotomy. Moreover, if for some reason a satisfactory vagotomy cannot be accomplished, it is possible that the surgeon would elect a radical rather than a conservative gastric operation. The left lobe of the liver does not interfere with exposure of the vagus.
1132
GE;ORW'; CHILE, JR.
In several of the earlier cases it seemed desirable to divide the avascular diaphragmatic attachments of the left lobe of the liver and reflect it to the,right to obtain better exposure of the diaphragm. With increasing experience this maneuver has not been necessary. A broad Deaver or malleable retractor inserted under the liver to lift it forward affords adequate exposure.
FIG. 317.-Locating anterior vagus nerve. Stomach is pulled downward, stretching elastic tissues of peritoneum and esophagus. Vagus is not elastic, becomes taut as a violin string, is easily palpable. Peritoneum is incised, and nerve is picked up on a nerve hook.
Identification of the Vagus.-The anterior vagus is quite constant in its location and usually can be found with little or no difficulty. The surgeon stands on the right side of the table. The stomach is grasped in the right hand with a moist tape and retracted downward, while an assistant retracts the liver anteriorly with a Deaver retractor to expose the lower part of the esophagus. By palpation with the left hand the operator can identify the Levine tube in the esophagus. Firm downward traction is then exerted on the stomach in such a way that the esophagus is stretched. The musculature of the esophagus, the peritoneum reflecting
SURGICAL TREATMENT OF PEPTIC ULCER
1133
from the stomach and the esophagus on to thc diaphragm, and the blood vessels of the stomach and esophagus are elastic, whereas the vagus nerve is nonelastic and stands out like a violin string, palpable and often visible beneath the peritoneum. As soon as the nerve is identified by palpation with index finger of the left hand, the traction on the stomach is delegated to an assistant who maintains it while the peritoneum overlying the nerve is incised and the nerve is picked up on a long nerve hook.
FIG. gI8.-Stripping vagus nerve. A wire loop is placed over vagus and is thrust upward into mediastinum lo strip small fibers from main trunk.
Its identity is quite unmistakable, and as soon as it is isolated it can be proved to be the vagus by following it upward through the esophageal hiatus in the diaphragm. The blood vessels of the stomach do not course in this direction nor does the esophageal hiatus transmit any other structure from the thorax to the abdomen (Fig. 317). The nerve is isolated by blunt dissection with a special instrument which is passed through the diaphragm and preferably higher so that there will be no question of failure to remove all accessible branches (Fig. 318). The nerve is then clamped with a Moynihan clamp, divided,
1134
GEORGE CRILE, JR.
and again divided several centimeters lower. The excised segment 2 to 5 cm. in length is examined by the pathologist to prove its identity.
Mter completion of the anterior vagotomy the forefinger of the left hand is inserted through the delicate peritoneum of the gastrohepatic omentum above the gastric vessels, as in mobilization of the stomach for total gastrectomy. The stomach is again pulled downward by the right hand, and the posterior vagus is located by palpation as a tense cord
FIG. 319.-Locating posterior vagus nerve. Posterior vagus usually lies behind and to the right of esophagus, is often well away from esophagus. Downward traction is exerted on stomach, and posterior vagus is located by palpation.
lying posterior to the esophagus in the areolar tissue. Occasionally it appears to be more to the right of the esophagus than directly posterior and may be surprisingly far away from it. While an assistant pulls the stomach and esophagus downward anteriorly and to the left, the nerve which is identified by the index finger of the left hand is picked up by a nerve hook and is dissected out, as in the case of the anterior nerve. It is important to make certain that it passes upward through the esophageal hiatus since there are vessels posteriorly that could be confused with the vagus if its course through the hiatus is not checked. Mter denervation
StIRGlCAL TREATMENT OF PEPTIC ULCER
113.5
of its branches a segment of the nerve is removed, as in the anterior vagotomy (Fig. 319). A final examination of the esophagus should be made to exclude the presence of additional branches coming down from above the diaphragm. It is not necessary to reconstruct the peritoneum. Attention is next directed to whatever operation on the stomach is desirable to prevent gastric retention. Pyloroplasty, gastric resection; gastroenterostomy and local excision of the ulcer each has its place, and the selection must depend on the size of the ulcer, its location, the amount of obstruction, the completeness of the vagotomy and on the preferences
FIG. 3£O.-Technic of pyloroplasty. After completion of vagotomy either a pyloroplasty or a gastroenterostomy is performed in order to facilitate emptying of the denervated stomach.
of the surgeon. Whenever feasible, pyloroplasty would appear to be the operation of choice because of its simplicity, because it entails no disturbance of normal mechanical or physiologic processes, and also because, if ulceration should recur, gastric resection could be performed with ease and without the difficulty involved in taking down a gastroenterostomy. But there are many cases in which the duodenum is fixed and foreshortened, in which pyloroplasty is not easily accomplished and gastroenterostomy is preferable. In about 50 per cent of the cases, however, a simple longitudinal incision through the pyloric muscle and the narrowest portion of the duodenum can be sutured transversely with correction of any tendency to obstruction (Fig. 3!l0). Before the pylorus
1136
GEORGE CRILE, JR.
is closed a finger should be inserted first into the duodenum and then into the stomach to make certain that there is no stenosis not corrected by pyloroplasty. Postoperative Course.-In addition to the safety of the procedure the immediate convalescence of the patient is smoother and more comfortable than that of any comparable group of patients with ulcer treated by gastric resection alone. Unpleasant complications such as vomiting from gastric retention and distress or a feeling of fullness after meals (the so-called "dump syndrome") have rarely occurred following vagotomy and pyloroplasty or gastroenterostomy: gastrojejunal ulceration has not been observed. The pain is relieved from the time of operation, and the appetite is good. The patients are out of bed on the first or second postoperative day. Usually by the eighth day they are eating a liberal diet, are free of symptoms and are able to go home. Gastric suction is maintained for one to four days until it is apparent that the stomach is emptying satisfactorily. In this way overdistention is avoided. Even if a gastroenterostomy or pyloroplasty has been done there may be some gastric retention, although the symptoms associated with the retention are minimal and soon subside. If vagotomy is not accompanied by some operation to drain the denervated stomach, retention is commonly observed, even if there was no demonstrable obstruction at the time of the operation. COMPLICATIONS OF VAGOTOMY
In the majority of cases vagotomy is easily accomplished and does not unduly prolong the operating time. Occasionally in obese patients or when exposure is poor, identification of the nerves is facilitated by slipping a Penrose drain or tape around the esophagus and drawing it downward. I have rarely found this maneuver necessary, and in one patient weighing 232 pounds and having a large left lobe of the liver and a high diaphragm, isolation of the esophagus proved to be dangerous. I had inserted my finger through the gastrohepatic omentum and was gently finger-dissecting around the totally unexposable esophagus when I suddenly found that I was lower than I had thought and had inserted my finger through the posterior wall of the stomach, where I could palpate the Levine tube. The proposed vagotomy was abandoned, and the small hole in the stomach was closed over as well as possible with fat. Two Levine tubes were left in the stomach with constant suction, and a pyloroplasty was performed. The patient was kept in Fowler's position wit1l the tubes in place for four days and made an uneventful convalescence. The symptoms of ulcer recurred in four weeks. This case, in which a gastric resection would have been difficult and
SURGICAL TREATMENT OF PEPTIC ULCER
1137
in which the patient was a poor surgical risk, was the only instance in which technical difficulties have arisen during vagotomy and the only one in which a proposed vagotomy was not completed. In several cases no large posterior vagus trunks could be located, but several small nerves were found and divided. Occasionally there are as many as five or six nerves instead of the usual main trunks. Only once was a blood vessel cut by mistake, and in this case the bleeding was easily controlled. Insulin tolerance tests have not been made following operation because pyloroplasty or gastroenterostomy causes a regurgitation of bile into the stomach and invalidates the test. SUMMARY 1. After two and one-half years of experience with transabdominal vagotomy coupled with pyloroplasty or gastroenterostomy for duodenal ulcer, we believe it to be (a) safer than gastric resection, (b) more effective than gastric resection in controlling the tendency to recurrent ulceration, and (c) attended by lesser morbidity and disability than is gastric resection. 2. The results obtained with vagotomy and gastroenterostomy or pyloroplasty justify this procedure as the treatment of choice when surgical intervention is indicated for duodenal ulcer. 3. Duodenal ulcer is primarily a medical problem, and operation should not be advised until medical management has been given a fair trial. 4. Most cases of gastric ulcer requiring operation should be treated by gastric resection rather than by vagotomy. 5. Vagotomy for gastric ulcer is not recommended unless (a) the ulcer is excised and examined microscopically, or (b) the ulcer is so high that it cannot be resected without performing a total gastrectomy or incurring undue risk. 6. Transabdominal vagotomy is the preferred treatment for gastrojejunal ulcer.
REFERENCES 1. Dragstedt, L. R.: Personal communication. 2. Crile, G., Jr.: Transabdominal Vagotomy versus Gastric Resection in Treatment of Duodenal Ulcer. Cleveland Clin. Quart. 14:264-270 (Oct.) 1947. 3. Collins, E. N. and Stevenson, C. W.: Bilateral Vagotomy in Treatment of Peptic Ulcer. Gastroenterology 10:205-215 (Feb.) 1948. 4. Renshaw, R. J. F. and (by invitation) Beck, R. H.: Peptic Ulcer; Evaluation of Surgical Treatment. Proc. Am. Federation Clin. Research 3:85-86 (April 28) 1947. 5. Editorial: Conservative Approach to Vagotomy. J. A. M. A. 134:786 (June 28) 1947.