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Total Gastrectomy
TOTAL GASTRECTOMY SAMUEL
F.
MARSHALL AND LOWELL
H.
BROWN
TOTAL gastrectomy refers to a radical operative procedure designed to remove the entire stomach, in most instances for extensive malignancy arising in that organ. During the past ten years there has been a recrudescence of interest in this method of operative approach to the problem of gastric malignancy, and in most instances this has been productive of real gain in the surgical treatment of advanced malignant disease. As it happens so often in major surgery, however, enthusiasm on the part of some surgeons for major technical procedures has resulted in perhaps unwise employment of this operation without regard to the postoperative morbidity or mortality or its effect upon prolongation of life. INDICATIONS
Surgery in its first effect should be designed to relieve suffering and to prolong life; in short, a postoperative existence which has the· hope of comfort, freedom from pain and reasonable usefulness on the part of those trusting their lives to the surgeon. Radical surgical procedures which are accompanied by high mortality, as is total gastrectomy, which give rise to immediate postoperative distress incident to any major operation and which do not prolong life beyond at least the anticipated average period of unoperated similar cases, can do little to enhance the reputation of the careful, thoughtful surgeon or of the surgical profession. Only recently we have noted in the literature unwarranted favorable conclusions in regard to total gastrectomy in a report of a small series of cases of total gastrectomy in which 30 per cent of the patients operated upon succumbed to recurrent malignant disease two to three months after operation. The natural expectancy of life in an unoperated series of cases similar to 30 per cent of the group referred to above in our experience has been five and one-half to six months. It is obvious to even a mildly critical observer of surgery that lesions of such extent and apparent hopelessness cannot be removed with any advantage to the patient, and such operations should not be undertaken; In spite of any misanplication of this surgical method, however, total gastrectomy is a valuable procedure and in properly selected cases is an extremely useful surgical approach to extensive n;ialignancy. Only. cases in which the stomach has been completely reti.toved with no portion of the stomach being left, with anastomosis of the esophagus· to some part of the small bowel, would be termed total gastrectomy. This anastomosis of the esophagus has been made to the duodenum or jejunum, but in the more recent re621
622
SAMUEL F. MARSHALL, LOWELL H. BROWN
ports of these cases, in most instances the esophagus has been anastomosed to the jejunum. Conner of Cincinnati, in 1884, was the first to report complete removal of the stomach in a man, but his patient died on the operating table. In 1897 Schlatter completed a successful total removal of the stomach and his patient lived one year and fifty-three days after operation. Numerous reports of single or isolated cases of successful total gastrectomy appear in the literature but until the last eight or ten years, no large series has been reported from any surgical clinic. Finney and Rienhoff, in 1929, reported an analysis of a corrected series
16 15 14 13
12
..,
1/)11
i
10
o .... 9 u
....~
8
~ 7
(l)
-I
6
<[
b5
.... 4 3 2
1927
1930
1935
1940
YEAR Fig. 237.-Number of total gastrectomies from 1927 to 1946, inclusive.
of 122 cases of total gastrectomy in the literature to that date. In this group they reported 5 cases of their own and stated that after critical analysis of the group of collected cases there were only 62 cases of true total gastrectomy and in 55 cases of this group of 122, less than 3 cm. of the stomach remained. The operative mortality rate was 53.8 per cent in the 67 patients who had definite total gastrectomies. In 1943, Pack and McNeer, in an excellent collective review of the literature to July 1, 1942, reported an analysis of 303 collected cases of total gastrectomy which included 20 cases in which total gastrectomy was performed by them. In their group of 20 cases there
623
TOTAL GASTREGrOMY
were 6 operative deaths, a mortality of 30. per cent, whereas there was an operative mortality of 37.6 per cent for 298 total gastrectomies collected over the period of 1884 to 1942. It is during the last ten years that interest in this problem has been most active and has been most productive of numerous reports of series of cases, especially of relatively larger groups of patients operated upon in clinics or by individual surgeons. In 1938, Dr. Lahey4 reported on 5 successful cases of total gastrectomy, and from that date our own interest in this operation was TABLE 1 TOTAL GASTRECTOMY, 1927-1946 INCLUSIVE
Year
1927 to 1937 inclusive 1938 1939 1940 1941 1942 1943 1944 1945 1946 Total
Total Gastrectomy, Number
Postoperative Deaths, Number
Operative Mortality, Per cent
12 4 12 8 10 13 16 7 7 6 95
5 1 3 5 5 2 3 1 1 1 27
41.6 25.0 25.0 63.0 50.0 15.4 18.7 14.3 14.3 16.6 28.4
From 1942 to January 1, 1947: 49 total gastrectomies-3 deaths operative mortality, 16.3 per cent Prior to 1942: 46 total gastrectomies-19 deaths operative mortality, 41.3 per cent
stimulated and the number of 1?atients having this operation increased rapidly (Fig. 237). In 1944, Lahey and Marsha1l6 reported the results to October 1943 in a group of 73 cases in which the operative mortality for the entire group was 33 per cent. This mortality rate, however, included the earlier cases of total gastrectomy, our first case being done in 1927. Prior to January 1, 1942, 46 total gastrectomies were performed in this clinic, with an operative mortality of 41.3 per cent. Since this report in 1944, total gastrectomy has been carried out in 22 additional
624
SAMUEL F. MARSHALL, LOWELL H. BROWN
cases up to January 1, 1947,. making in all a series of 95 cases of total gastrectomy done at the Lahey Clinic. The operative mortality in 49 consecutive cases in which total gastrectomy was done since January 1, 1942, has been 16.3 per cent-a noteworthy reduction in operative mortality as compared to the rate (41.3 per cent) prior to January 1, 1942 (Table 1). The reduction in operative mortality can be attributed to a number of factors: experience gained in the performance of the operation, better operative technic, better selection of cases, improved anesthesia and better understanding of preoperative and postoperative care of these patients, particularly in relation to knowledge of blood chemistry, vitamins, and blood proteins. Of considerable significance, also, 50
40
PARTIAL GASTRECTOMY 30
20
TOTAL GASTRECTOMY ..... ,/0,......
10
-~-o_--
.- _ ... _e-
---.•--
---"""'"
·------e
__ 0
OL-__~O-~-------·-·O~-----~----~----+_----~--_+----~~--+_--~~
YEAR
1936
1937
1938
1939
1§40
1941
1942
1943
1944
1945
Fig. 238.-Resection for carcinoma of the stomach 1936 to 1945, inclusive. The number of total gastrectomies compared with the number of partial resections done each year is shown.
is the effect of chemotherapy, particularly sulfonamide and penicillin therapy. These drugs have been invaluable to us in improving our results and avoiding postoperative complications such as wound infection, peritonitis and chest complications. One other factor which has been of inestimable value, and which is not peculiar to total gastrectomy but to all types of major surgery, has been the early recognition and the equally prompt treatment of pulmonary atelectasis; thus avoiding postoperative deaths resulting from serious pulmonary complications. It is also of interest to note the relative proportion of total to partial gastrectomies over the period from 1936 to 1945 (Fig. 238). During a six year period, 1939 to 1944 inclusive, there was a relatIvely higher proportion of total gastrectomies in relation to partial gastrec-
TOTAL GASTREGrOMY
625
tomies than before 1939 or 1945. Perhaps this was the result of an effort to increase the operability in cases of advanced cancer and with it a resultant rise in operative mortality. With increase in experience and with improvement in certain technical features, however, the operative mortality dropped remarkably (Table 1). Out of this has also come a better selection of cases fitted for such a radical procedure and the mortality rate has more or less remained constant from 1942· to 1946, as may be noted in Table 1. From 1944 to 1946 total gastrectomy was done in even fewer cases. This, we are sure, is based upon better selection of cases and the realization that one must be able to remove cleanlv all demonstrable cancer if results are to be all that is desired. . Waugh and Fahlund reported a similar experience with total gastrectomy at the Mayo Clinic. They reported a series of 77 cases of total gastrectomy done by the abdominal route from 1917 to 1943 inclusive; in 33 cases from 1917 to 1939 operation was performed with a mortality of 60.6 per cent, whereas in a group of 44 cases in which operation was carried out from 1940 to 1943 inclusive, the operative mortality was 31.8 per cent. Twenty of these patients were operated on in 1943 with 5 operative deaths, a mortality of 25 per cent. In the main, there is only one definite indication for total gastrectomy and that is when a tumor so involves a stomach that it cannot be completely removed by partial gastrectomy. Total gastrectomy is to be avoided if all demonstrable tumor cannot be removed at the time of operation. Evidence of widespread or distant metastases precludes the employment of this operation and in some of the cases this can be determined before laparotomy is carried out; in others this decision has to be made after the abdomen is opened. Should there be involvement ·of adjacent organs, the operation is advisable only if these involved areas can be included in the radical extirpation of the malignant lesion, and this seldom proves to be possible. Portions of the pancreas can be included in this surgical removal. The spleen should be removed in the majority of these cases; in our hands this is always done without increase in mortality and its removal really simplifies the complete mobilization of the stomach. 5 Total gastrectomy is indicated in tumors of the cardia and fundus or in widespread malignant disease confined to the stomach, such as linitis plastica. When roentgen-ray studies indicate extensive involvement of the stomach with carcinoma and total gastrectomy must be considered, it is important to determine whether the esophagus is involved. The roentgen-ray studies in most cases will indicate encroachment upon the esophagus; dilatation or obstruction of the esophagus is evidence of this and further information can be obtained by esophagoscopy. Should roentgenologic and endoscopic examination indicate involvement of the esophagus, transthoracic resection of the cardia or even total gastrectomy should be done by this route.
626
SAMUEL F. MARSHALL, LOWELL H. BROWN
All of this group of patients (95) have had resection by the transabdominal route and none of the transthoracic resections are included in these figures. In general, we prefer transabdominal approach in all these cases. This type of operation carries less operative risk and morbidity and a more thorough removal of lymphatic nodes can be
Fig. 239.- The omentum has been detached from the transverse colon. The lesser omental cavity has been entered, allowing the posterior gastric wall to be visualized. Involvement of the pancreas or retroperitoneal tissues can be found readily and operability at once determined before proceeding with total gastrectomy.
done through the abdomen. It is obvious that there will be some cases in which the transthoracic approach will be desirable. Improvements in anesthesia have contributed in a large measure to lowered operative mortality over the past five years. We have routinely used continuous spinal anesthesia after the method proposed by Lemmon for all these cases. Anesthesia can be maintained for long periods with perfect re-
TOTAL GASTREcrOMY
627
laxation and without shock. It can also be supplemented by curare or sodium pentothal given intravenously if greater relaxation is needed or if it is desired to have the patient asleep during the procedure. TECHNIC
We will not attempt in this paper to give detailed direction of the operative technic of total gastrectomy as employed at the Lahey
Posterior Wall of :stomach
Fig. 240.- The duodenum has been divided and closed by inverting sutures. Note splenic vessels which can be divided and ligated easily to pennit splenectomy. With division and ligation of left gastric vessels, mobilization of entire stomach is now practically complete.
Clinic, as this has been given fully in previous communications. The essential features of the operation are shown in the illustrations (Figs. 239 to 242). A long left rectal incision is made extending to the costal
628
SAMUEL F. MARSHALL, LOWELL H. BROWN
margin and to a level below the umbilicus. The location and the amount of involvement of the stomach are determined and a search is made for peritoneal implants and liver metastases. If the stomach can be mobilized and the esophagus and diaphragm are not invaded with neoplasm, gastrectomy can be proceeded with. We always detach the omentum from the colon, which permits ready exposure of the lesser omental cavity and permits the surgeon to ascertain if there is extension of tumor to the pancreas or retroperitoneal structures. As already stated, the spleen is always removed as propased by Dr. Lahey when total gastrectomy is done and we have seen no difficulty arise.
Fig. 241.-The detached stomach is turned up over the left costal margin wit!). the esophagus still attached to the stomach. The manner of attaching jejunum to esophagus is illustrated; thus beginning the formation of the esophagojejunal anastomosis.
from this procedure as Graham has suggested may occur with splenectomy. It facilitates mobilization of the stomach and permits removal of involved splenic groups of nodes. Mter the stomach is completely mobilized, the stomach is turned upward over the left costal margin and pot detached from the esophagus until the anastomosis between the f:lsophagus and jejunum is begun by completing the posterior suture line of the anastomosis. Entero-enterostomy is always done between efferent and afferent loops of jejunum, which will allow direct passage ofhne and pancreatic juices from the proximal to the distal loop of jejunum without coming in contact with the lower end of the esoph-
I
I
TOTAL GASTREcrOMY
629
agus. This anastomosis will also prevent dilation and obstruction of the proximal jejunal loop which may occur at the esophagojejunal anastomosis as a result of edema or narrowing of the esophagus at the
Fig. 242.-The completed esophagojejunaI anastomosis is illustrated. Note enteroenterostomy between proximal and distal loops of jejunum.
suture line. Dilation of the proximal loop with liquid contents has been responsible for leaks at the anastomosis and subsequent contamination and peritonitis. RESULTS
There were 27 postoperative deaths in this series of 95 patients. The majority of deaths (15) resulted from contamination and infection, such as peritonitis, abscess and so forth. Eight deaths followed sedous chest complications such as pneumonia, mediastinitis and pulmonary infarction. It is conceivable that many of these complications in the earlier cases could have been avoided by the use of chemotherapeutic agents, but it is important to emphasize that clean surgery, lack of trauma and contamination are still the most important factors in preventing these complications. Cardiovascular compIlcations accounted for 4 deaths. We shall not attempt to discuss the Rnal postoperative results in this series, as this phase is covered by Smith in a report of 89 cases in this group, to which 6 additional cases haye been added.
630
SAMUEL F. MARSHALL, LOWELL H. BROWN
SUMMARY The results in 95 cases in which total gastrectomy was performed at the Lahey Clinic between 1929 and January 1, 1947, are reviewed. The operative mortality in 46 cases in which operation was done during the period from 1927 to January 1942, was 41.3 per cent. The operative mortality in 49 consecutive cases since 1942 was 16.3 per cent. REFERENCES 1. Conner, P. S.: Report of case of complete resection of the stomach presented at the meeting of the Cincinnati Academy of Medicine, Nov. 3, 1884. M. News, New York, 45:578, 1884. 2. Finney, J. M. T. and ReinhofI, W. F. J.: Gastrectomy. Arch. Surg., 18:140162 (Jan.) 1929. 3. Graham, R. R.: Total gastrectomy for carcinoma of stomach. Arch Surg., 46:907-914 (June) 1943. 4. Lahey, F. H.: Complete removal of stomach for malignancy, with report of 5 surgically successful cases. Surg., Gynec. & Obst., 67:212-223 (Aug.) 1938. 5. Lahey, F. H. and Marshall, S. F.: Combining splenectomy with total gastrectomy. Surg., Gynec. & Obst., 73:341-344 (Sept.) 1941. 6. Lahey, F. H. and Marshall, S. F.: Indications for, and experiences with, total gastrectomy based upon 73 cases of total gastrectomy. Ann. Surg., 119: 300--320 (Mar.) 1944. 7. Pack, G. T. and McNeer, G.: Total gastrectomy for cancer. Intemat. Abst. Surg., 77:265-299 (Oct.) 1943. 8. Schlatter, Carl: Ueber Emahrung und Verdauung nach voIIstandiger Entfernung des Magens; Oesophagoenterostomie, beim Menschen. Beitr. z klin. Chir., 19:757-776, 1897. 9. Smith, F. H.: Total gastrectomy. Report of 89 cases. Surg., Gynec. & Obst. (In press.) to. Waugh, J. M. and Fahlund, G. T. R.: Total gastrectomy. S. CLIN. NORTH AMERICA, 25:903-917 (Aug.) 1945.
F.
MARSHALL AND LOWELL
H.
BROWN
TOTAL gastrectomy refers to a radical operative procedure designed to remove the entire stomach, in most instances for extensive malignancy arising in that organ. During the past ten years there has been a recrudescence of interest in this method of operative approach to the problem of gastric malignancy, and in most instances this has been productive of real gain in the surgical treatment of advanced malignant disease. As it happens so often in major surgery, however, enthusiasm on the part of some surgeons for major technical procedures has resulted in perhaps unwise employment of this operation without regard to the postoperative morbidity or mortality or its effect upon prolongation of life. INDICATIONS
Surgery in its first effect should be designed to relieve suffering and to prolong life; in short, a postoperative existence which has the· hope of comfort, freedom from pain and reasonable usefulness on the part of those trusting their lives to the surgeon. Radical surgical procedures which are accompanied by high mortality, as is total gastrectomy, which give rise to immediate postoperative distress incident to any major operation and which do not prolong life beyond at least the anticipated average period of unoperated similar cases, can do little to enhance the reputation of the careful, thoughtful surgeon or of the surgical profession. Only recently we have noted in the literature unwarranted favorable conclusions in regard to total gastrectomy in a report of a small series of cases of total gastrectomy in which 30 per cent of the patients operated upon succumbed to recurrent malignant disease two to three months after operation. The natural expectancy of life in an unoperated series of cases similar to 30 per cent of the group referred to above in our experience has been five and one-half to six months. It is obvious to even a mildly critical observer of surgery that lesions of such extent and apparent hopelessness cannot be removed with any advantage to the patient, and such operations should not be undertaken; In spite of any misanplication of this surgical method, however, total gastrectomy is a valuable procedure and in properly selected cases is an extremely useful surgical approach to extensive n;ialignancy. Only. cases in which the stomach has been completely reti.toved with no portion of the stomach being left, with anastomosis of the esophagus· to some part of the small bowel, would be termed total gastrectomy. This anastomosis of the esophagus has been made to the duodenum or jejunum, but in the more recent re621
622
SAMUEL F. MARSHALL, LOWELL H. BROWN
ports of these cases, in most instances the esophagus has been anastomosed to the jejunum. Conner of Cincinnati, in 1884, was the first to report complete removal of the stomach in a man, but his patient died on the operating table. In 1897 Schlatter completed a successful total removal of the stomach and his patient lived one year and fifty-three days after operation. Numerous reports of single or isolated cases of successful total gastrectomy appear in the literature but until the last eight or ten years, no large series has been reported from any surgical clinic. Finney and Rienhoff, in 1929, reported an analysis of a corrected series
16 15 14 13
12
..,
1/)11
i
10
o .... 9 u
....~
8
~ 7
(l)
-I
6
<[
b5
.... 4 3 2
1927
1930
1935
1940
YEAR Fig. 237.-Number of total gastrectomies from 1927 to 1946, inclusive.
of 122 cases of total gastrectomy in the literature to that date. In this group they reported 5 cases of their own and stated that after critical analysis of the group of collected cases there were only 62 cases of true total gastrectomy and in 55 cases of this group of 122, less than 3 cm. of the stomach remained. The operative mortality rate was 53.8 per cent in the 67 patients who had definite total gastrectomies. In 1943, Pack and McNeer, in an excellent collective review of the literature to July 1, 1942, reported an analysis of 303 collected cases of total gastrectomy which included 20 cases in which total gastrectomy was performed by them. In their group of 20 cases there
623
TOTAL GASTREGrOMY
were 6 operative deaths, a mortality of 30. per cent, whereas there was an operative mortality of 37.6 per cent for 298 total gastrectomies collected over the period of 1884 to 1942. It is during the last ten years that interest in this problem has been most active and has been most productive of numerous reports of series of cases, especially of relatively larger groups of patients operated upon in clinics or by individual surgeons. In 1938, Dr. Lahey4 reported on 5 successful cases of total gastrectomy, and from that date our own interest in this operation was TABLE 1 TOTAL GASTRECTOMY, 1927-1946 INCLUSIVE
Year
1927 to 1937 inclusive 1938 1939 1940 1941 1942 1943 1944 1945 1946 Total
Total Gastrectomy, Number
Postoperative Deaths, Number
Operative Mortality, Per cent
12 4 12 8 10 13 16 7 7 6 95
5 1 3 5 5 2 3 1 1 1 27
41.6 25.0 25.0 63.0 50.0 15.4 18.7 14.3 14.3 16.6 28.4
From 1942 to January 1, 1947: 49 total gastrectomies-3 deaths operative mortality, 16.3 per cent Prior to 1942: 46 total gastrectomies-19 deaths operative mortality, 41.3 per cent
stimulated and the number of 1?atients having this operation increased rapidly (Fig. 237). In 1944, Lahey and Marsha1l6 reported the results to October 1943 in a group of 73 cases in which the operative mortality for the entire group was 33 per cent. This mortality rate, however, included the earlier cases of total gastrectomy, our first case being done in 1927. Prior to January 1, 1942, 46 total gastrectomies were performed in this clinic, with an operative mortality of 41.3 per cent. Since this report in 1944, total gastrectomy has been carried out in 22 additional
624
SAMUEL F. MARSHALL, LOWELL H. BROWN
cases up to January 1, 1947,. making in all a series of 95 cases of total gastrectomy done at the Lahey Clinic. The operative mortality in 49 consecutive cases in which total gastrectomy was done since January 1, 1942, has been 16.3 per cent-a noteworthy reduction in operative mortality as compared to the rate (41.3 per cent) prior to January 1, 1942 (Table 1). The reduction in operative mortality can be attributed to a number of factors: experience gained in the performance of the operation, better operative technic, better selection of cases, improved anesthesia and better understanding of preoperative and postoperative care of these patients, particularly in relation to knowledge of blood chemistry, vitamins, and blood proteins. Of considerable significance, also, 50
40
PARTIAL GASTRECTOMY 30
20
TOTAL GASTRECTOMY ..... ,/0,......
10
-~-o_--
.- _ ... _e-
---.•--
---"""'"
·------e
__ 0
OL-__~O-~-------·-·O~-----~----~----+_----~--_+----~~--+_--~~
YEAR
1936
1937
1938
1939
1§40
1941
1942
1943
1944
1945
Fig. 238.-Resection for carcinoma of the stomach 1936 to 1945, inclusive. The number of total gastrectomies compared with the number of partial resections done each year is shown.
is the effect of chemotherapy, particularly sulfonamide and penicillin therapy. These drugs have been invaluable to us in improving our results and avoiding postoperative complications such as wound infection, peritonitis and chest complications. One other factor which has been of inestimable value, and which is not peculiar to total gastrectomy but to all types of major surgery, has been the early recognition and the equally prompt treatment of pulmonary atelectasis; thus avoiding postoperative deaths resulting from serious pulmonary complications. It is also of interest to note the relative proportion of total to partial gastrectomies over the period from 1936 to 1945 (Fig. 238). During a six year period, 1939 to 1944 inclusive, there was a relatIvely higher proportion of total gastrectomies in relation to partial gastrec-
TOTAL GASTREGrOMY
625
tomies than before 1939 or 1945. Perhaps this was the result of an effort to increase the operability in cases of advanced cancer and with it a resultant rise in operative mortality. With increase in experience and with improvement in certain technical features, however, the operative mortality dropped remarkably (Table 1). Out of this has also come a better selection of cases fitted for such a radical procedure and the mortality rate has more or less remained constant from 1942· to 1946, as may be noted in Table 1. From 1944 to 1946 total gastrectomy was done in even fewer cases. This, we are sure, is based upon better selection of cases and the realization that one must be able to remove cleanlv all demonstrable cancer if results are to be all that is desired. . Waugh and Fahlund reported a similar experience with total gastrectomy at the Mayo Clinic. They reported a series of 77 cases of total gastrectomy done by the abdominal route from 1917 to 1943 inclusive; in 33 cases from 1917 to 1939 operation was performed with a mortality of 60.6 per cent, whereas in a group of 44 cases in which operation was carried out from 1940 to 1943 inclusive, the operative mortality was 31.8 per cent. Twenty of these patients were operated on in 1943 with 5 operative deaths, a mortality of 25 per cent. In the main, there is only one definite indication for total gastrectomy and that is when a tumor so involves a stomach that it cannot be completely removed by partial gastrectomy. Total gastrectomy is to be avoided if all demonstrable tumor cannot be removed at the time of operation. Evidence of widespread or distant metastases precludes the employment of this operation and in some of the cases this can be determined before laparotomy is carried out; in others this decision has to be made after the abdomen is opened. Should there be involvement ·of adjacent organs, the operation is advisable only if these involved areas can be included in the radical extirpation of the malignant lesion, and this seldom proves to be possible. Portions of the pancreas can be included in this surgical removal. The spleen should be removed in the majority of these cases; in our hands this is always done without increase in mortality and its removal really simplifies the complete mobilization of the stomach. 5 Total gastrectomy is indicated in tumors of the cardia and fundus or in widespread malignant disease confined to the stomach, such as linitis plastica. When roentgen-ray studies indicate extensive involvement of the stomach with carcinoma and total gastrectomy must be considered, it is important to determine whether the esophagus is involved. The roentgen-ray studies in most cases will indicate encroachment upon the esophagus; dilatation or obstruction of the esophagus is evidence of this and further information can be obtained by esophagoscopy. Should roentgenologic and endoscopic examination indicate involvement of the esophagus, transthoracic resection of the cardia or even total gastrectomy should be done by this route.
626
SAMUEL F. MARSHALL, LOWELL H. BROWN
All of this group of patients (95) have had resection by the transabdominal route and none of the transthoracic resections are included in these figures. In general, we prefer transabdominal approach in all these cases. This type of operation carries less operative risk and morbidity and a more thorough removal of lymphatic nodes can be
Fig. 239.- The omentum has been detached from the transverse colon. The lesser omental cavity has been entered, allowing the posterior gastric wall to be visualized. Involvement of the pancreas or retroperitoneal tissues can be found readily and operability at once determined before proceeding with total gastrectomy.
done through the abdomen. It is obvious that there will be some cases in which the transthoracic approach will be desirable. Improvements in anesthesia have contributed in a large measure to lowered operative mortality over the past five years. We have routinely used continuous spinal anesthesia after the method proposed by Lemmon for all these cases. Anesthesia can be maintained for long periods with perfect re-
TOTAL GASTREcrOMY
627
laxation and without shock. It can also be supplemented by curare or sodium pentothal given intravenously if greater relaxation is needed or if it is desired to have the patient asleep during the procedure. TECHNIC
We will not attempt in this paper to give detailed direction of the operative technic of total gastrectomy as employed at the Lahey
Posterior Wall of :stomach
Fig. 240.- The duodenum has been divided and closed by inverting sutures. Note splenic vessels which can be divided and ligated easily to pennit splenectomy. With division and ligation of left gastric vessels, mobilization of entire stomach is now practically complete.
Clinic, as this has been given fully in previous communications. The essential features of the operation are shown in the illustrations (Figs. 239 to 242). A long left rectal incision is made extending to the costal
628
SAMUEL F. MARSHALL, LOWELL H. BROWN
margin and to a level below the umbilicus. The location and the amount of involvement of the stomach are determined and a search is made for peritoneal implants and liver metastases. If the stomach can be mobilized and the esophagus and diaphragm are not invaded with neoplasm, gastrectomy can be proceeded with. We always detach the omentum from the colon, which permits ready exposure of the lesser omental cavity and permits the surgeon to ascertain if there is extension of tumor to the pancreas or retroperitoneal structures. As already stated, the spleen is always removed as propased by Dr. Lahey when total gastrectomy is done and we have seen no difficulty arise.
Fig. 241.-The detached stomach is turned up over the left costal margin wit!). the esophagus still attached to the stomach. The manner of attaching jejunum to esophagus is illustrated; thus beginning the formation of the esophagojejunal anastomosis.
from this procedure as Graham has suggested may occur with splenectomy. It facilitates mobilization of the stomach and permits removal of involved splenic groups of nodes. Mter the stomach is completely mobilized, the stomach is turned upward over the left costal margin and pot detached from the esophagus until the anastomosis between the f:lsophagus and jejunum is begun by completing the posterior suture line of the anastomosis. Entero-enterostomy is always done between efferent and afferent loops of jejunum, which will allow direct passage ofhne and pancreatic juices from the proximal to the distal loop of jejunum without coming in contact with the lower end of the esoph-
I
I
TOTAL GASTREcrOMY
629
agus. This anastomosis will also prevent dilation and obstruction of the proximal jejunal loop which may occur at the esophagojejunal anastomosis as a result of edema or narrowing of the esophagus at the
Fig. 242.-The completed esophagojejunaI anastomosis is illustrated. Note enteroenterostomy between proximal and distal loops of jejunum.
suture line. Dilation of the proximal loop with liquid contents has been responsible for leaks at the anastomosis and subsequent contamination and peritonitis. RESULTS
There were 27 postoperative deaths in this series of 95 patients. The majority of deaths (15) resulted from contamination and infection, such as peritonitis, abscess and so forth. Eight deaths followed sedous chest complications such as pneumonia, mediastinitis and pulmonary infarction. It is conceivable that many of these complications in the earlier cases could have been avoided by the use of chemotherapeutic agents, but it is important to emphasize that clean surgery, lack of trauma and contamination are still the most important factors in preventing these complications. Cardiovascular compIlcations accounted for 4 deaths. We shall not attempt to discuss the Rnal postoperative results in this series, as this phase is covered by Smith in a report of 89 cases in this group, to which 6 additional cases haye been added.
630
SAMUEL F. MARSHALL, LOWELL H. BROWN
SUMMARY The results in 95 cases in which total gastrectomy was performed at the Lahey Clinic between 1929 and January 1, 1947, are reviewed. The operative mortality in 46 cases in which operation was done during the period from 1927 to January 1942, was 41.3 per cent. The operative mortality in 49 consecutive cases since 1942 was 16.3 per cent. REFERENCES 1. Conner, P. S.: Report of case of complete resection of the stomach presented at the meeting of the Cincinnati Academy of Medicine, Nov. 3, 1884. M. News, New York, 45:578, 1884. 2. Finney, J. M. T. and ReinhofI, W. F. J.: Gastrectomy. Arch. Surg., 18:140162 (Jan.) 1929. 3. Graham, R. R.: Total gastrectomy for carcinoma of stomach. Arch Surg., 46:907-914 (June) 1943. 4. Lahey, F. H.: Complete removal of stomach for malignancy, with report of 5 surgically successful cases. Surg., Gynec. & Obst., 67:212-223 (Aug.) 1938. 5. Lahey, F. H. and Marshall, S. F.: Combining splenectomy with total gastrectomy. Surg., Gynec. & Obst., 73:341-344 (Sept.) 1941. 6. Lahey, F. H. and Marshall, S. F.: Indications for, and experiences with, total gastrectomy based upon 73 cases of total gastrectomy. Ann. Surg., 119: 300--320 (Mar.) 1944. 7. Pack, G. T. and McNeer, G.: Total gastrectomy for cancer. Intemat. Abst. Surg., 77:265-299 (Oct.) 1943. 8. Schlatter, Carl: Ueber Emahrung und Verdauung nach voIIstandiger Entfernung des Magens; Oesophagoenterostomie, beim Menschen. Beitr. z klin. Chir., 19:757-776, 1897. 9. Smith, F. H.: Total gastrectomy. Report of 89 cases. Surg., Gynec. & Obst. (In press.) to. Waugh, J. M. and Fahlund, G. T. R.: Total gastrectomy. S. CLIN. NORTH AMERICA, 25:903-917 (Aug.) 1945.