Triangular wedge resection of lesser curvature gastric ulcers

Triangular Wedge Resection of Lesser Curvature Gastric Ulcers RICHARD W. ZOLLINGER, M.D., DUDLEY F. BRIGGS, M.D. AND PATRICK J. CREEDON, M.D., Columbus,

From tbe Department of Surgery, Mount Carmel Hospital and from Tbe Department of Surgery, College of Medicine, Obio State University, Tbe Obio State University Healtb Center, Columbus, Obio.

[7]. The medical profession has the impression that the five year saIvage rate for cancer of the stomach has remained at a constant rate of 5 per cent in recent years. The Iiterature substantiates this impression [8]. Most physicians are convinced that the mortaIity for ulcer operations on the stomach varies from 2 to 7 per cent [6,9,10]. The postgastrectomy sequeIae are known to be rather severe in 25 per cent or more patients when extensive amounts of stomach are removed [6]. It seems that procrastination as a result of the over-reIiance on our present diagnostic methods is the cause of our faiIure to improve the five year surviva1 for patients with cancer of the stomach. Few can deny that the history of the benign gastric ulcer is in many ways as maIignant as that of cancer itseIf. It has been stated that as few as 20 to 30 per cent of patients are cured with medica treatment [r~]. Even the most conservative physicians state that the ulcer is subject to recurrence in at Ieast 40 per cent of patients [r2]. In foIIow-up studies others estimate that approximateIy 25 to 55 per cent of patients have significant disabiIity such as pain, pyrosis, nausea and vomiting [11,x3]. It has been cIaimed that as many as 17 per cent of patients may have massive or chronic bIeeding and in 2 per cent the ulcer wiI1 perforate [I I]. Obstruction seIdom occurs in gastric Iesions. The mortality rate for gastric ulcer treated by medica measures is approximately 4.5 per cent [rj]. There are, at present, certain generalty accepted indications for surgery in patients with a gastric uIcer. These are massive hemorrhage, perforation, obstruction, failure to respond to medica treatment, recurrence after an initial response and evidence of maIignancy.

GASTRIC ULCER is a refractory, disabhng and Iife-threatening disease. The diagnosis is IargeIy dependent on roentgenograms. The gravity of these observations is not appreciated unIess the roentgenoIogist suggests the possibiIity of a mahgnancy. The diagnosis is based on the Iocation, size, eIevation and surrounding rigidity of the uIcer area and, at best, is 88 per cent accurate [I]. Routine medica management is customary for the outpatient, and is frequentIy prescribed for the hospitaIized patient, unIess the x-ray diagnosis of cancer is suggested. AdmittedIy, certain areas of the stomach, such as the cardia, fundus, greater curvature and prepyIoric area have a higher incidence of cancer [z-6]. (Fig. I .) Many more uIcers occur on the Iesser curvature area of the stomach, and aIthough a smaIIer percentage are maIignant, mathematicaIIy, more neopIasms are found here [2-61. (Fig. 2.) Therefore, the Iocation of gastric ulcers has been overemphasized as a means of differentiating benign and malignant uIcers. Ideally, a11 patients with gastric uIcers shouId be hospitalized. Diagnostic aids shouId incIude roentgenograms, gastric analysis, exfoIiative cyand possibIy gastroscopy. toIogic studies, These studies shouId make the diagnostic accuracy approximateIy 90 per cent. Even the most astute diagnosticians wiI1 claim roentgenograms and gastroscopy are 88 per cent accurate, and exfoliative cytologic studies are 95 per cent successfu1 [I]. Unfortunately, these aids are not effective in determining the presence of a smal1 cancer that may be curabIe

A

American

Journal

of Surgery.

Volume

ref.

January

1963

Ohio

40

TrianguIar

Wedge Resection

of Gastric

UIcers

GASTRIC ULCER % Location

1737 COLLECTEDSERIES 254 WLJGNAt’JClES

FIG. I. Approximate distribution series from the Iiterature [z-61.

of gastric

ukers,

Why shouId not surgery be used for a11 gastric uIcers, providing they have been adequateIy studied, treated and yet do not hea in a six to eight week period? Our medica associates argue that the mortaIity and morbidity associated with extensive gastric surgery is too high a price for the patient with a benign uIcer to pay, and this is a reasonable objection. Surgery for gastric ulcer has paraIIeIed that of peptic ulcer in generaI: nameIy, subtota1 resection. Recently, conservative measures have become more generaIIy accepted for duodena1 uIcers, because our understanding of the pathophysiology of the uIcer diathesis has increased. It seems expedient that every effort be made by surgeons to deveIop technics for removing benign gastric ulcers, leaving as much stomach intact as possibIe. Such an operation shouId have a mortaIity of I per cent or Iess, and shouId not be compIicated by postgastrectomy symptoms in more than 5 per cent of the patients. To achieve this, the surgeon must have the services of an abIe pathoIogist, skiIIed in frozen section diagnosis. The accuracy of the diagnosis should approach perfection if the entire uIcer can be removed [rq]. This paper presents a fIexibIe procedure for Iesser curvature uIcers extending from the incisura to the juxta-esophagea1 area, which lends itseIf, in a conservative way, to the treatment of benign ulcers, but which can readiIy be

1,737

benign

and 254 malignant.

Collected

modified into an adequate cancer operation. Such a conservative procedure shouId relieve the patient of the disabIing symptoms of a chronic gastric uIcer, Iessen the IikeIihood of a possible perforation or hemorrhage, and identify the unsuspected curabIe malignancy; thus, increasing the five year saIvage rate of the Iatter from 5 to 40 per cent [8]. PREVIOUS

SURGICAL

PROCEDURES

Heretofore, the usua1 operation for gastric uIcer has been a standard dista1 gastrectomy [j]. Modifications, as indicated to remove a high Iying Iesser curvature uIceration, are the Schoemaker adaptation of the BiIroth I operation, or the Pauchet procedure (Fig. 3a.) Tanner [ 151 has even extended the above operation further, by freehand excision of a tongue of the Iesser curvature to encompass a high Iying cardial uIcer, rotating the lesser curvature anteriorIy to expose a posterior uIcer, and reconstructing a new Iesser curvature. Other methods designed for higher Iying uIcers have been the proximal subtota1 resection, and the KeIIing-MadIener procedure [r6]. Both of these have obvious disadvantages. (Fig. 3b and c.) Wangensteen has advocated a segmenta resection of the acid-bearing area of the stomach, combined with pyloromyotomy and vagotomy, which is appIicabIe to both gastric and duodena1 uIcers [r7]. (Fig. 3d.) 41

ZoIIinger,

Briggs and Creedon

GASTRIC ULCER % Malignant

LESSER

CURVATURE

13

1737 COLLECTED SERIES 254 MAUGNANGIES-15% FIG. 2. Distribution

of 254 malignant

&em.

Recent conservatism in gastric uker operations is advocated by numerous authors [I??201. They have performed IocaI excision of the lesion, with frozen section examination, cIosure of the stomach, vagotomy and a drainage procedure such as gastrojejunostomy or pyIoropIasty. (Fig. se.) Others have done vagotomy with antral resection, and even more recently, pyIoropIasty aIone. (Fig. 3f.) As long ago as 1924, AIfred Strauss performed IongitudinaI resection of the lesser curvature of the stomach for uIcer in twentyone patients [21], accompanying this procedure with a pyIoromyotomy and an anterior and posterior transverse gastropIasty. (Figure 38.) We are __ proposing - a technic which conforms cIoseIy to this operation described by Strauss, in the hope that folIowing excision of the uker and carefu1 examination by the pathoIogist, we couId obtain a IongitudinaI cIosure of the stomach and avoid the hourgIass deformity and constriction, which often accompanies the routine transverse cIosure after wedge excision. Furthermore, the use of clamps (to be described) is heIpfu1 in preventing spilIage with contamination, and faciritates cIosure of the resuItant defect, eIiminating the probIem of eIusive mucosa1 bIeeders. It, aIso, aIIows cIosure of the entire length of the Iesser curvature without tension. Most important of aI1, it permits the entire uIcer specimen to be removed for examination by the pathoIogist. This technic

CoIIected

series from the Iiterature

12-q.

was deveIoped in six mongre1 dogs, and is the so-caIIed trianguIar wedge resection. METHODS

AND

MATERIALS

Wedge resection of the upper portion of the Iesser curvature of the stomach was performed in six mongre1 dogs. (Fig. 4.) The dogs were anesthetized with intravenous pentobarbita1; respiration was maintained with a positive pressure oxygen apparatus through an endotrachea1 tube. The abdomen was opened through a mid-Iine incision carried superiorIy to the Ieft of the xiphoid process. Further exposure was achieved by mobirizing the Ieft Iobe of the Iiver after division of the trianguIar ligament, dividing the gastrohepatic Iigament, Iigating the Ieft gastric artery, and cutting both vagus nerves. (Fig. 4.) A Iong crushing AIIen cIamp was appIied from the juxtaesophagea1 area over the anterior and posterior gastric waIIs in a pIane paraIIe1 to the direction of the esophagus. A second crushing cIamp was appIied in a simiIar manner, extending from the junction of the Iesser curvature and the gastric antrum to the tip of the first cIamp. (Fig. 4a.) The triangIe which formed, had as its base the lesser curvature and as its sides, the two cIamps. The wedge of tissue between the cIamps was excised. The handIes of the cIamps were then depressed in the pIane of the Iesser curvature, transforming the previous angle between the cIamps into a straight line. 42

TrianguIar

Wedge Resection

OPERATIVE

of Gastric

UIcers

PROCEDURES

FIG. 3. Previous surgica1 procedures: (a) Schoemaker-Pauchet; (b) Esophagogastrostomy; (c) Kelling-Madlener; (d) Segmental resection; (e) Vagotomy and drainage procedure; (f) PyIoropIasty; (g) Strauss operation.

the greater curvature of the stomach. Inasmuch, as biIatera1 vagotomy had been done, a pyIoropIasty of the Heinecke-Mikulicz type was done. (Fig. 4c.)

(Fig. 4b.) The gastric wail beneath the clamps was then sutured, using a continuous through and through catgut suture. The cIamps were then removed. This suture line was reinforced with siIk sutures in the seromuscuIar Iayer. It is realized that, in the event of application of this procedure to a human patient with a large indurated Iesser curvature uIcer, that freehand excision by sharp dissection and remova of the uIcer may be necessary in view of the circumstances encountered. In other words, it may be impossibIe in such a situation to appIy the cIamps without severeIy compromising the Iumen of the remaining portion of the stomach. Using the technic described above in animaIs, the stomach was tubuIated and no constrictive deformity resuIted. Care was taken to insure that an adequate channeI was preserved aIong

EXPERIMENTAL

RESULTS

The six dogs subjected to trianguIar wedge resections were folIowed seven to fifteen weeks. The nutritional status of each improved or was maintained. Barium meaIs were given to each of the animaIs and seria1 roentgenograms showed satisfactory IiIIing and emptying of the stomachs with no abnormality of the gastric mucosa. At the time of sacrifice, the stomach showed satisfactory healing with no gross deformity. No excessive scarring or diaphragm formation was present. We believed that this procedure was adaptabIe as a simpIe and 43

ZoIIinger,

TRIANGULAR

Briggs

and Creedon

WEDGE RESECTION

FIG. 4. Operative technic of trianguIar wedge resection: (a) Showing application of cIamps; (6) Longitudinal closure of Iesser curvature; (c) CompIetcd

procedure showing vagotomy and pyIoropIasty.

A sixty-three year old white woman CASE II. (R. G.) was operated on in March 1961. Studies discIosed a Iarge gastric ulcer in the midportion of the lesser curvature. A triangular wedge resection of the lesion was carried out and frozen section was negative for malignancy. The curvature was cIosed IongitudinalIy along with a vagotomy and a Heinecke-MikuIicz pyIoropIasty. The postoperative course was benign and the patient has done we11 for a period of one year. Roentgenograms made one year after surgery were satisfactory. The patient’s strength and persona1 satisfaction with this operation are excelIent. She has maintained her normal weight and strength and has carried out full domestic activities.

one for the excision of carefulIy seIected high Iying Iesions of the lesser curvature. We believe that it is a satisfactory operation for the uker diathesis in that it combines vagotomy with a drainage procedure. It, thus, fulfiIIs the objective criteria for the surgical management of gastric ulcer: namely, the reduction of gastric acid, the prevention of stasis, and the remova of the uIcer itseIf. definitive

CLINICAL

APPLICATION

The procedure which we have described has been performed, in essence, in seven human patients. The foIIowing are the case histories:

CASE III. A forty-five year oId Negro man (E. J.) entered the HospitaI in January 1961. A wedge excision of an uIcer on the midportion of the Iesser curvature was done and frozen section biopsy was benign. The lesser curvature was closed in a Iongitudinal manner and a Heinecke-Mikulicz pyIoropIasty and bilateral vagotomy were performed. The patient has been we11 for seventeen months. Postoperative roentgenograms were satisfactory. The patient has maintained norma weight and strength, and evaIuates the resuIt of surgery as excellent.

A fifty-one year oId white woman (G. D.) was operated on in January 1961. A Iarge gastric uIcer on the lesser curvature, measuring 4.5 by 4 by z cm. was removed. Frozen section biopsy was benign. The Iesion was excised in a V shape and the Iesser curvature was cIosed in a IongitudinaI manner. A Finney pyloroplasty, vagotomy and a temporary gastrostomy were performed. The postoperative course was uneventful except for some minor diIIicuIties with early feedings. Roentgenograms made seventeen months since the origina surgery showed satisfactory resuIts. She has maintained her norma weight and strength, and is pIeased with the operation. CASE

I.

CASE IV. Surgery for intractabIe pain caused by a penetrating Iesser curvature uIceration was per44

TrianguIar

Wedge

Resection

of Gastric

UIcers

for the benign gastric uIcer produces a high incidence of unsatisfactory resuIts.

formed on patient (C. F.) in August 1960. The ulcer was excised by freehand dissection. Frozen section biopsy was negative and the Iesser curvature was closed in a Iongitudinal manner. HeineckeMikulicz pyloropIasty and vagotomy were done. He has been we11 for twenty-two months. Postoperative roentgenograms were negative; the patient has maintained normal weight and strength and evaIuates the resuIt of surgery as excellent.

CONCLUSION

A modification of an operation deveIoped by Strauss for the management of gastric uIcers of the Iesser curvature of the stomach proxima1 to the pylorus has been presented. A trianguIar wedge of tissue is removed from this area of the gastric waI1; presented for frozen section anaIysis; and the Iesser curvature is cIosed IongitudinaIIy, forming a gastric tube. This IongitudinaI cIosure of the Iesser curvature is combined with a pyIoropIasty and a vagotomy. It appears that such a conservative operation applied to seIected patients with lesser curvature ulcers above the pyIorus, wouId constitute an eminentIy satisfactory procedure for contro1 of many gastric Iesions.

1960, a thirty-seven year old CASE V. August white woman (J. C.) was operated on for an intractable uIcer of nine years’ duration. A penetrating high lesser curvature gastric ulcer was excised by freehand dissection and frozen section biopsy was benign. The Iesser curvature was closed IongitudinaIIy and a Heinecke-Mikulicz pyloropIasty and vagotomy were done. She has been we11 for twenty-two months. Recent roentgenograms are satisfactory; she has maintained normal weight and strength and evaluates her resuIts as exceIIent.

Acknowledgment: We are gratefu1 to Doctors Robert M. ZoIIinger, W. H. Teachnor, V. Cross and T. F. Lewis for their kindness in permitting us to use some of their cases in this study.

CASE VI. A thirty-nine year oId white man (E. H.) was operated on in September rg6o for bleeding and intractabIe pain. A Iarge penetrating uIcer of the Iesser curvature was removed by free hand dissection. The lesser curvature was closed IongitudinaIly and a Heinecke-MikuIicz pyloropIasty and vagotomy were done. He has been we11 for twenty-one months. Recent roentgenograms have been satisfactory with no evidence of recurrent ulceration. He has maintained his weight and

REFERENCES

1. KLATZ, A. P., KIRSNER, J. B. and PALMER, W. L. An evamation of gastroscopy. Gastroenterology, 27: 221, 1954. 2. DELAURENTIS. D. A. and ROSEMOND. G. 0. The clinica course of 250 gastric ulcer patients. Arch. Surg., 83: 674, 1961. 3. HAYES, M. A. The gastric ulcer probIem. Gustroenterology, 29: 609, 1955. 4. MARSHALL, S. F., JENSEN, A. and DAVIDSON, C. M. Gastric uIcer. Am. J. Surg., IOI : 273, 1961. 5. PLENK, H. P. and LIN, Ru-KAN. Gastric ulcer and gastric carcinoma. Am. Surgeon, 20: 348, 1954. 6. DENKEWALTER, F. R. and WATMAN, R. N. Conservative surgica1 treatment of a11 gastric uIcers. Arch. Surg., 75: 558, 1957. 7. LANWR, J. H. Small ulcerative lesions in the stomach; benign or maIignant, Chapter IO, p. 217. In: The Phvsioloev and Treatment of Peptic Ulcer. Chicago, 1y59. The University of Chicago Press. 8. JAMES, A. G. Cancer Prognosis ManuaI. Cancer, page 41 f 9. HARKINS, H. and NYHUS, L. Chapt. 6A, p. 162. In: Surgery of the Stomach and Duodenum. St. Louis. 1462. LittIe. Brown and Comoanv. IO. Survey Committee, Ohio Chapter, Ame&can”CoIIege of Surgeons. EIective operations performed for duodena1 ulcer. with their mortaIitv. resuIts in a survey in selected Ohio hospitaIs:‘Am. J. Surg., g6: 365, 1958. I 1. WELCH, C. E. and BURK, J. F. An appraisaI of the treatment of gastric ulcers. Surgery, 44: ~43, 1958. 12. SMITH, F. H. and JORDAN, S. M. Gastric ulcer:

strength and evaluates the result of surgery as exceIIent. CASE VII. Surgery for weight Ioss and hemorrhage was performed on a seventy year oId woman (E. H.) in May 1962. A juxta-esophageal penetrating ulcer was removed with freehand excision. Frozen section biopsy was negative. The lesser curvature was cIosed longitudinally and a biIatera1 vagotomy, pyIoromyotomy and an anterior transverse gastroplasty were done. The immediate postoperative course has been satisfactory. Roentgenograms made on the fifteenth postoperative day show satisfactory emptying of the stomach with no gross deformity. SUMMARY

An earIy surgica1 approach for gastric uIcer is warranted because: (I) every gastric ulcer must be considered a potentia1 maIignancy; (2) earIy operation wiI1 improve the surviva1 rate of those who have a malignant ulcer; (3) there are no compIeteIy accurate diagnostic criteria for differentiation between benign and maIignant ulcers; and (4) the medica therapy 45

ZoIIinger, a study

of 600 cases. Gastroenterology,

Briggs and Creedon

I I: 575,

have recentIy shown, it carries a low mortality rate and perhaps it will carry a reasonabIe recurrence rate. LLOYD M. NYHUS (Seattle, Wash.) : We recentIy have been interested in this type of operation for a11 benign gastric ulcers. I would Iike to stress that the wedge resection is primariIy to guard against missing an early carcinoma. A drainage procedure prevents antra1 stasis; thus, it diminishes the gastrin output from the antrum. Dragstedt is credited with expounding the postmate that gastric ulcer is a separate disease entity from duodenal uIcer. If this is indeed the case, then pyloroplasty should effectively cure the gastric uIcer. These are interesting observations, which must be studied further. Further, as surgeons we shouId not forget that the medica mortaIity for the treatment of gastric ulcer is significant. We always hear about the surgica1 mortality, but what is the medical mortality for the continued “conservative” treatment? We have two reports in the Iiterature: those from the Lahey CIinic of about 3.2 per cent medical mortality, and Dworkin and coIIeagues from Cleveland reporting a 4.2 per cent mortality. These patients died from perforation, hemorrhage and carcinoma which had been missed in the diagnosis. The surgica1 mortaIity wiI1 fare exceedingly we11 in comparison. We have good grounds to operate earlier and earIier on gastric ulcer, not worrying necessarily about the cancer problem; but, that operative treatment, whether it be a limited gastric resection or that suggested by Zollinger and colleagues today, is much better treatment for this disease entity. DR. CLAUDE E. WELCH (Boston, Mass.): This paper is intriguing. A number of statements are in it, however, that I think we ought not to alIow to pass unchallenged because, if we do, we are tacitly assuming we agree with what has been said. One statement the authors have made is about the dangers of gastrectomy. They have made another statement about the poor resuIts following gastrectomy. I believe both of them require further evaIuation. I will mereIy mention the folIow-up results of a Iarge series of patients treated by gastrectomy. I think there probably is nothing better in the Iiterature than that which has come from the Presbyterian Hospital, by Dr. Harvey and his group; in many folIow-up studies from the Mayo Clinic that you have a11 read; and our studies in our hospital which confirm exactly the same fact that the follow-up results are exceIIent after gastrectomy for gastric ulcer. I find it a IittIe hard to satisfy myself practically that the operation just discovered will be a better procedure. Furthermore, the theoretical implications elude me somewhat, too. I just can’t quite see the point

1958.

13. DWORKEN, H. J., ROTH, H. T., DUBER, H. C. and

BERGER, D. G. Observations on the course of benign gastric ulcer and factors affecting its prog
15. TANNER, N. C. Non-maIignant conditions of the upper stomach. Ann. Roy. Coil. Surgeons England, IO: 45, 1952. 16. MADLENER, M. PyIorectomy in gastric uIcer. Zentralbl. Cbir., 30: 1313, 1923. 17. WANGENSTEEN. 0. H. SegmentaI gastric resection for peptic uIeer. J. A. I~J. A., 14,: 18, 1952. 18. ZOLLINGER, R. M. and STEWART,W. R. C. SurgicaI management of gastric ulcer. J. A. M. A., 171: 2056, ‘959. 19. WEINBERG, J. C., MOVIUS, H. G. and DAGRADI, A.

The

conservative

resection

for gastric

ulcer.

Am. J. Gastroenterol., 22: 136, 1954. 20. FARRIS, J. N. and SMITH, G. K. The roIe of pyIoroplasty in the surgical treatment of gastric ulcer. Ann.-Surg., 154: 293, 1961.

21. STRAUSS, A. LongitudinaI

resection

of the Iesser

curvature with resection bf the pyIoric sphincter for gastric uIcer: an experiment and cIinica1 study. J. A. M. A., 82: 1765, 1924.

DISCUSSION ROGER D. WILLIAMS (CoIumbus, Ohio): Dr. ZoIIinger’s exceIIent presentation does not leave me anything to say regarding surgica1 technic, but it does require our re-evaIuation of the possibility of using Iocal excision combined with vagotomy and pyIoropIasty in the treatment of most gastric uIcers, certainIy the benign ones. About five years ago Drs. Watman and Denkewaiter in our department evaIuated our experience with gastric uIcer and expressed concern over the high mortaIity and morbidity when radica1 gastric procedures were used, and suggested lesser procedures and certainly more limited resection. A more recent review of 5 I 3 cases at our hospita1 with gastric uIcer is near completion. There were 197 initiaIly treated surgically. Forty-two later came to surgery after medica treatment. More conservative surgery has been carried on in the past few years since Watman and DenkewaIter suggested this; however, our overal mortality is stiI1 high, 5.8 per cent. I do not think we can, as yet, say what our recurrence rate is going to be with the procedure which Dr. ZoIlinger did not reaIIy emphasize added to his local excision: nameIy, vagotomy and pyIoropIasty; but certainly it has a sound physioIogic basis. I for one beIieve it should be given greater consideration because, as Wineberg and others

46

TrianguIar Wedge Resection of Gastric UIcers of vagotomy in the presence of the gastric ulcer that has a notoriously low acid level anyway. Finally, a gastric resection may be considerably easier on the patient than the operation presented here. R. T. SHACKELFORD (Baltimore, Md.): I had no intention of discussing anything this morning, and I did not know what the program was until my train got in. I shall not discuss the theoretical advantages of local excisions versus gastrectomies because I cannot document it with any series of there is one technical aspect my own; however, (and this paper seemed to be a technical paper) that I would like to mention. Eric Nanson, who is now at Saskatoon, first suggested the idea to me, and we have found it quite useful, Some of these uIcers on the lesser curvature are so close to the esophagus that to excise them makes it somewhat difficult to make an adequate closure, or at least one that you are certain will not cause stenosis. So, at Dr. Nanson’s suggestion, in the few patients in whom we have done this procedure, we have passed the old-time large-bore gastric tube. At first we passed it through the esophagus into the stomach at the time of operation, but, subsequently, we have placed it up through the gastrotomy wound. Then, by placing the tube in the esophagus, one can excise the ulcer on the lesser curvature, leaving the esophagus in continuity with the stomach on the other three-fourths of the circumference. With the gastric tube in place, acting as a temporary stent over which one can sew, one can reconstruct the continuity without as much danger of constricting the esophagogastric junction, and then remove the tube. As far as the usefulness of the procedure is concerned, there are not many patients in whom these anatomical conditions present that problem; however, there are some. We have used it with complete satisfaction. I cannot tell you how many times, but I should say at least in a dozen patients, without any untoward effects. As far as the local excision of gastric ulcers is concerned, I have done this a good many times particularly in older persons, and so far, without being able to document it by any figures, I do not regret having done so. We do not add a vagotomy. DR. GEORGE L. JORDAN, JR. (Houston, Texas): I want to support the concept of limited gastrectomy. I think that it is an excellent operation, and I do not think that we can perform the procedure described with less mortality in our institution. In our experience most operative deaths occur in patients operated upon for bleeding or other complications requiring emergency procedures. If we have a patient who is a good-risk, who comes to surgery for gastric uIcer at 8 a.m., with the

operating room and personnel in good condition, as well as the patient, the mortality rate in our hands is less than I per cent for limited gastrectomy. If the gastrectomy is limited, the postoperative sequelae have, in our experience, been quite minimal. In most patients with gastric ulcer, WC do a Billroth I operation, which limits the nutritional and dumping problems that may occur following this procedure. I still think that gastrectomy is an excellent procedure. DR. JOHN M. WAUCH (Rochester, Minn.): I would like to add a note of caution, myself. One of the reasons that we do gastrectomy is to take care of an early malignancy that may be entirely unsuspected in an ulcer. I believe that any time one does a local excision of an ulcer and it proves to be malignant, one has already done an incomplete operation and may actually disseminate cells. So, before I would do a IocaI excision (and I have done so on a few high lesions), I would want to be satisfied, at least, that everything would point to the fact that I am dealing with a benign lesion. HENRY N. HARKINS (Seattle, Wash.): Dr. Nyhus, now supported by Dr. Zollinger, has persuaded me as to the value of this type of approach. I do think, however, in fairness to gastric resection, that one technical point which may bear on the after-results, which have been referred to, should be more commonly recognized. I believe Dr. Griflith and later Dr. Burge independently pointed this out to me, namely, that in some gastric resections, particularly of the Shoemaker type, the surgeon, particularly if he is not interested in selective vagotomy, and, therefore (as I used to), does not even know about the hepatic and ceIiac rami, will inadvertently cut them. I do not think anyone can say exactly how often this has occurred; however, I am sure that, in retrospect, I have probably cut one or both of these rami in well up into hundreds of cases; I am sure (and this is pureIy surmise) that this has probably been done by thousands of other surgeons in many thousands of cases. Therefore, my point is this. Perhaps some ofthe ill effects of gastric resection may be caused by inadvertent cutting of the celiac and hepatic rami. If we accept (as I do) that cutting these rami does cause some postvagotomy difficulty, some surgeons, who may even be opposed to vagotomy, may inadvertently, unknowingly and unwittingly “antiselective” perform vagotomy. Furthermore, this is more apt to occur in patients with gastric ulcers. I do not mean by this to say that when carcinoma or fear of carcinoma is the main indication for the procedure, one should pull one’s punches as far as cutting the celiac and hepatic rami is concerned; however, in the average operation for

47

ZoIIinger,

Briggs

and Creedon the stomach; I am talking about uIcers in the Iimited area of the Iesser curvature of the stomach. When one encounters them, it seems that everyone on earth has that type of uIcer but, in reality, it does not occur often. PriestIey reported that in their large series only 5 per cent of ulcers occurred in this area. This is a Iimited procedure for a very Iimited area. I want to thank the discussants for their fine comments.

gastric or duodena1 uIcer, attention should be paid to this. DR. RICHARD W. ZOLLINCER (closing): I do not know the answer to vagotomy either, but actuaIly the sectioning of the vagus was more of a mechanicaI effort to mobiIize these uIcerations that are high Iying on the Iesser curvature rather than the actual physioIogic effect of a section of the vagus. The main point I wanted to bring out is that I am not taIking about uIcers in the distal third of

48