PARTIAL GASTRIC RESECTION FOR PEPTIC ULCER SAMUEL
Partial gastrectomy is still a most important surgical method for treatment of peptic ulcer, whether duodenal, gastric or jejunal, and at the Lahey Clinic we continue to place most of our reliance for permanent effective treatment of ulcer on resection of the stomach. With the advent of vagotomy we had hoped that many of the difficulties of resection, both technically and postoperatively, could be avoided. As Wilkinson has pointed out, with vagotomy the stomach could be left intact, a large percentage (88) of ulcer patients could be relieved of pain, and anacidity or low acid values could be obtained in a fairly large group of cases, but this decrease in gastric acid could not always be attained nor was the resultant anacidity permanent in many cases. At the Lahey Clinic vagotomy has been carried out in over 90 cases. In a recent review of 6~ patients with vagotomy, it was evident that these patients had more postoperative difficulty, more severe and more persistent symptoms and just as many recurrent ulcers as a similar group of patients who had partial gastric resection only. The problem of vagotomy is by no means settled but the complications and dangers should be recognized as well as the benefits to be obtained from this lesser technical procedure as opposed to the more radical operation of partial resection. FACTORS ESSENTIAL FOR GOOD RESULTS
Partial gastrectomy can be done with a large margin of safety and with excellent results in the majority of cases but any good postoperative results depend upon a number of factors. First, the results depend upon the proper selection of patients to be submitted to surgical treatment. The indications for surgical treatment have been restated many times (tnd are clear: perforation, repeated massive hemorrhages, obstruction and failure to relieve symptoms by adequate medical treatment, demand surgical interference. Gastric ulcers which fail to heal under medical treatment, or recur after healing, likewise demand resection. It is our feeling that vagotomy should almost never be used for gastric ulcer, since surgical interference is advised because of the uncertainty of the ulcer being benign or malignant. In a previous study of the problem of gastric ulcer, we found ~6 malignant ulcers among 131 gastric ulcers, an incidence of 19.6 per cent; these patients were submitted to surgery because of failure of the ulcer to heal or because of recurrence of gastric ulcer after healing under medical treatment. 767
SAMUEL F. MARSHALL
Second, good results after resection depend upon adequate resection; two-thirds or three-fourths of the stomach must be removed to prevent recurrent ulcer. Removal of the pylorus or antral area of the stomach carries as much surgical risk as a high resection and will result in recurrent ulcer in a large percentage of cases. Third, operation, whether partial resection or gastroenterostomy, does not permit the patient to eat everything and to avoid long-continued postoperative ulcer management. He should follow a careful dietary regimen and be under the care of his gastroenterologist for a long period of time to avoid recurrent ulcer. ~ ) Lastly, meticulous attention to technical details of the operation, avoidance of contamination from visceral contents during operation, control of hemorrhages and avoidance of trauma will make for lower mortality and will contribute greatly to an uneventful, uncomplicated postoperative recovery. The type of technical procedure employed in partial resection of the stomach makes no great difference if sufficient stomach is removed and if the ulcer is also removed, which can be done in almost every case if the relationship of the ulcer, especially duodenal ulcer, to important structures such as the common bile duct is recognized. Resections which do not include removal of the ulcer are palliative resections and are not true radical partial resections and should not be termed so. This type of palliative resection may result in a high percentage of recurrent ulcers. The Finsterer resection with exclusion of the ulcer is such an operation and has not been used in this clinic for seven or eight years. In an early series of cases in which the Finsterer procedure was occasionally employed, ulceration recurred in over 50 per cent. In several instances in which a jejunal ulcer recurred after a high resection but with the duodenal ulcer not removed, we were able to effect healing of the recurrent ulcer by simply excising the unremoved antral part of the stomach. MODIFIED HOFFMEISTER TECHNIC
The method of resection of the stomach routinely employed in the clinic for the past ten years has been a modification of the Hoffmeister technic of partial gastric resection. The gastrojejunal anastomosis is made anterior to the transverse colon with the proximal loop of jejunum placed at the greater curvature of the stomach. As stated previously, a radical resection of the stomach is uniformly employed with removal of two-thirds or three-fourths of the stomach. It is our opinion that recurrence of ulcer with few exceptions is related to a large degree to insufficient removal of the stomach. A left paramedian or transrectus incision is made, extending from the
PARTIAL GASTRIC RESECTION FOR PEPTIC ULCER
left costal margin to the level of or below the umbilicus; the incision is made long enough to permit adequate exposure of the stomach and duodenum. The incision on the left side of the abdomen is preferred since the pylorus normally lies in the mid line of the abdominal cavity and the duodenum is only slightly to the right. This incision allows ready approach to the fundus and even the cardia of the stomach and thus permits a high resection to be carried out easily under the left costal margin. The muscles, fascia and other layers of the incision in the abdominal wall are protected by abdominal pads containing a layer of waterproof cellophane between the gauze to prevent contamination of the incision when the lumen of the stomach or jejunum is opened into during the operation. After exploration of the abdominal viscera, the location of the ulcer is identified and its relation to other structures is determined. Should the ulcer be located in the duodenum, its relationship to the common bile duct and ampulla of Vater must be established before attempting to mobilize the duodenum and pylorus in preparation for resection. In chronic, deeply penetrating duodenal ulcers, in which there is much inflammatory reaction about the ulcer, a layer of scar tissue envelops the first and second portions of the duodenum which will conceal the outline of the duodenum. The convexity of the duodenum is mobilized by division of this scar tissue and peritoneum parallel to the upper border of the duodenum, the course of the duodenum and its relation to the gastrohepatic ligament are easily delineated and the duodenum may be turned medially. If the ulcer is low in the duodenum or adherent to the gastrohepatic ligament, the common bile duct must be exposed and visualized (Fig. ~85). The common bile duct is then incised longitudinally, and the ampulla of Vater is dilated by the Bakes dilators in order that a limb of a rubber T-tube can then be passed into the duodenum. This placing of the T-tube into the bile duct and through the ampulla of Vater into the duodenum establishes definitely the course of the bile duct and its relation to the ulcer: The ulcer may then be removed without danger of injury to the common bile duct. This is a simple but extremely important maneuver in preventing injuries to the bile duct with their resultant stricture formation and postoperative obstruction to the flow of bile into the duodenum. Intubation of the common bile duct does not increase postoperative morbidity or adversely affect mortality but, on the contrary, greatly facilitates mobilization of the duodenum and removal of the ulcer in difficult cases. However, it is well to emphasize that exposure and intubation of the common bile duct are necessary in only a few cases, that is, those in which the ulcer is low in the duodenum or induration and inflammation about the ulcer involves the structures about the common duct.
SAMUEL F. MARSHALL
When it is definitely established that a duodenal ulcer can be removed without injury to these important adjacent structures, the greater and lesser curvatures of the stomach are mobilized by clamping, section and ligation of the blood supply in the gastrocolic and gastrohepatic omentum (Fig. 286). If the patient is obese or the omentum is thickened with fat, it is detached from the colon and resected with the stomach. This makes the resection much easier and permits an easier exposure and direct ligation of large vessels around the pylorus; it also permits an anterior gastrojejunostomy to be made more easily. Mobilization of the pyloric area and duodenum can be facilitated by passing a sponge poste-
SITE OF ULCER
Fig. ~85.-Pyloric end of stomach and first part of duodenum. The ulcer is adherent to the gastrohepatic ligament and common bile duct. The common bile duct has been exposed, incised longitudinally and a rubber T-tube inserted with the long limb passed through the ampulla of Vater into the duodenum. This will aid materially in establishing the location of the ampulla of Vater and permit easier dissection of the duodenum and ulcer from the common bile duct and pancreas.
rior to the stomach and using this as a traction tape to elevate the stomach. Following mobilization of the pylorus and duodenum, the duodenum is divided and the distal divided end closed by one of several methods (Fig. 287). The mobilization of the lower end of the stomach and the duodenum is made readily if one recalls that the gastrocolic omentum and mesocolon are fused just below the antrum of the stomach. This area of fusion consists of avascular areolar tissue which separates easily if the peritoneum over the pancreas is divided at the point of reflection onto the posterior wall of the stomach (Fig. 288), permitting the mesocolon with its middle colic vessels to be brushed down gently with gauze. This will expose the gastroduodenal artery as it courses over the head of the pancreas posterior to the antrum of the stomach.
PARTIAL GASTRIC RESECTION FOR PEPTIC ULCER
This artery can be divided and ligated at the inferior border of the pancreas. The chronic indurated ulcer which is usually on the posterior wall of the duodenum may be adherent to the pancreas and usually such an ulcer has penetrated the wall of the duodenum so that the ulcer base
Fig. !t86.-Mobilization of the stomach and duodenum. The gastrocolic and gastrohepatic omenta have been divided and ligated. The right gastric vessels are shown along the superior border of the duodenum. Note the relation of the common bile duct to the duodenum and ulcer. The gauze sponge is passed around the stomach and used to elevate the stomach.
consists of pancreatic and scar tissue. It is not necessary to remove this base; the ulcer is removed by detaching the ulcer orifice on the duodenal wall from its ulcer base. With the duodenum divided and the distal end closed, the stomach is drawn upward and to the left of the abdomen (Fig. 289). If the resection is done for gastric ulcer, the ulcer is often found attached to the pancreas or liver. This adherent indurated ulcer can be detached easily
Fig. Q87.-Closure of the duodenum; several methods may be used as shown in a and b. a, The duodenal stump may be sutured with a running stitch of chromic 0 catgut (1) and the clamp removed (Q). The closed duodenal end is then inverted with interrupted mattress sutures of black silk (3, 4). b, When the duodenal stump after mobilization and removal of the ulcer is short, no clamp is applied in order that duodenal length may be conserved; a Connell stitch of chromic 0 catgut is used to invert the open end of the duodenum; this is then reinforced with interrupted mattress sutures of black silk. This in turn may be further reinforced by suturing the closed end of the duodenum against the scarred head of the pancreas.
Fig. Q88.-The layers of the peritoneum are shown in relation to the omentum, stomach and lesser peritoneal cavity. Recognition of the anatomy of these peritoneal layers permits easier mobilization of the pyloric part of the stomach and duodenum.
PARTLAL GASTRIC RESECTION FOR PEPTIC ULCER
under direct vision by sharp or blunt dissection. The left gastric artery is visualized and divided at a high level along the lesser curvature of the stomach. The lesser curvature of the stomach is cleaned of omental tissue and this is likewise done on the greater curvature, ligating one or
:Fig. ~89.-The duodenum has been divided and closed by inversion. The stomach is elevated and drawn to the left. a, The von Petz clamp has been applied at the level at which the stomach is to be divided, leaving about one-third or one-fourth of the stomach above the clamp. b, The stomach is now divided between the double row of inserted clips with the cautery. Note that the borders of the stomach above the clips have been cleaned of omental tissue to permit more accurate inversion of corners and more accurate anastomosis of jejunum to stomach.
two of the short gastric vessels. This clearing of the borders of the stomach will permit accurate approximation and inversion of the gastric wall at the borders of the stomach (Fig. 289) ; about two-thirds or threefourths of the stomach is removed. Before dividing and removing this portion of the stomach, however, the loop of jejunum which is to form the gastrojejunal anastomosis close to the ligament of Treitz is brought
SAMUEL F. MARSHALL
anterior to the colon. This will prevent unnecessary contamination at the time of division of the stomach, so that the protecting abdominal pads do not have to be disarranged to select the proper loop of jejunum. The von Petz clamp is now applied at right angles to the long axis of
Fig. 290.-The lesser curvature end of the transected stomach is inverted with clips in place with a continuous chromic 0 catgut suture which is then reinforced with interrupted mattress sutures of black silk (see a). The jejunum is sutured to the posterior wall of the stomach at the site of anastomosis with interrupted sutures of black silk. The jejunal lumen is opened into by longitudinal incision and the stomach is opened by cutting away the clips in the uninverted end of the stomach. This will form the gastrojejunal stoma. A second posterior continuous interlocking stitch of chromic catgut is then placed and this is continued anteriorly as a Connell stitch (b and c) to close the anastomosis and form the stomal orifice.
the stomach at the level at which the stomach is to be divided and the clips are inserted (Fig. 289). A Payr clamp is applied just distal to the double row of clips and the von Petz clamp is removed. A Babcock clamp is applied at the level of the clips on the lesser and greater curvature to
PARTIAL GASTRIC RESECTION FOR PEPTIC ULCER
support and elevate the gastric stump when the stomach is divided by cautery between the two rows of clips. The upper one-half or two-thirds of the transected end of the stomach with the clips in place is inverted with a continuous suture of No. 0 chromic catgut on an atraumatic needle (Fig. 290). This suture line is reinforced with a second layer of interrupted mattress sutures of silk. The lower uninverted end of the stomach along the greater curvature will Yform the gastric stoma into the jejunum.
Fig. Q91.-Completion of the gastrojejunal anastomosis which completes the partial resection of the stomach. a, Note that the chromic catgut stitch which forms the second posterior suture layer is continued anteriorly as a Connell suture which closes the lumen of the stomach and of the jejunum to form the gastrojejunal stoma. b, The completed anastomosis which is reinforced with interrupted sutures of black silk. Note that the jejunum beyond the anastomosis is sutured to the closed and inverted end of the stomach. Note also that, for reinforcement, the gastrocolic omentum is sutured in the angle formed by the stomach and jejunum at the greater curvature of the stomach.
The selected loop of jejunum is brought anterior to the transverse colon and is sutured to this uninverted end of the stomach with interrupted mattress sutures of silk. The gastrojejunal stomal orifice should be about three fingerbreadths in width. The jejunum is opened by a longitudinal incision and the un inverted end of the stomach is opened by excising the crushed portion with its clips (Fig. 290). Contamination is prevented by suction of jejunal and gastric contents. All active bleeding points are ligated by fine catgut. A second posterior suture of chromic catgut is begun at the right end of the anastomosis and carried as an interlocking stitch through all layers of the jejunum and gastric wall toward the greater curvature of the stomach. This posterior interlocking suture of catgut is then continued
SAMUEL F. MARSHALL
anteriorly from the greater curvature end to the right as a Connell stitch, serving to invert the gastric and jejunal edges and thus closing the anastomosis and forming the gastrojejunal stoma. This anterior suture line is reinforced with interrupted (Lempert) sutures of silk. The distal jejunal loop beyond the stomal area toward the lesser curvature is buttressed against the closed inverted end of the transected stomach to reinforce the suture line and to remove tension on angle sutures of the anastomosis (Fig. 291). The gastrojejunal angle at the greater curvature is reinforced by suturing the divided end of the gastrocolic omentum to this angle. The proximal jejunal loop is thus placed at the greater curvature. Entero-enterostomy between the proximal and distal jejunal loops should not be done. This not only is unnecessary for proper drainage of stomach but deflects the alkaline duodenal contents from the stomal TABLE 1 PARTIAL GASTRIC RESECTION FOR PEPTIC ULCER
Duodenal ulcer ..................... Gastric ulcer ........ .............. Jejunal ulcer ...................... Gastrojejunocolic fistula . . . . . . . . . . . . . Total operated cases
Number of Patients
Number of Postoperative Deaths
Operative Mortality, Per cent
710 205 133 31
18 3 3 2
2.53 1.46 2.3 6.5
orifice. This is an important factor in preventing recurrent ulcer at the gastrojejunal anastomosis. The abdominal cavity is inspected for bleeding points before closing the abdominal wound, which is done without drainage. The ab~ominal wound is closed in layers of the peritoneum, fascia, muscle and skin; the peritoneum is closed with a continuous suture of chromic catgut. By use of the waterproof cellophane pads, any contamination of the abdominal wall incision is prevented. We are, therefore, able to employ interrupted silk sutures in approximating muscle, fascia, subcutaneous tissue and skin. This is also a layer closure. Should the patient be elderly or have poor abdominal wall tissues, further reinforcement of the incision may be obtained with a few interrupted retention sutures of heavy silk. These latter stitches are rarely necessary and the large percentage of these wounds heal without infection, and rarely is disruption of wound observed. The operative mortality
r PARTIAL GASTRIC RESECTION FOR PEPTIC ULCER
following partial gastric resection for peptic ulcer for the past 12 years has been 2.4 per cent in 1079 cases (Table 1). Partial gastrectomy can be done with low mortality even with many patients who have serious complicated ulcers. Postoperative results following partial gastrectomy are, in general, excellent. REFERENCES 1. Marshall, S. F. and Welch, M. L.: Results of treatment for gastric ulcer. J. A. M. A. 136:748-75fl (Mar. 13) 1948. fl. Wilkinson, S. A.: Present status of the peptic ulcer problem. J. A. M. A. 138:805-807 (Nov. 13) 1948.