PRINCIPLES OF OPERATIVE PROCEDURES
Treatment of a peptic, gastric, or duodenal ulcer begins with medical management (diet, antacid therapy, anti-secretory drugs). No rule of thumb can be given or used to fix the period of time during which medical treatment should be continued in the hope of improvement in symptoms. A great variety of individual factors must be considered before concluding that further medical efforts to regulate diet, habits, and gastric secretion will not be helpful. In general, however, the physician and patient should avail themselves of the benefit of consultation with the surgeon if the symptoms do not abate after several months of adhering strictly to sound medical therapy. Failure of response with a well-planned regimen, repeated recurrences of severe symptoms, intractable ulcer pain, lack of endoscopic evidence that the ulcer has not completely healed after a few months (even though marked subjective improvement is noted), persistence of blood in the stool, and any other signs of a threatening complication are fairly universally accepted as indications for surgical intervention.
When one
suspects that a gastric lesion is not a benign process, a surgical consultation
is helpful. The precise operative procedure in the presence of an established,
or even suspected, malignancy depends largely upon the size, site, and extent
of the lesion. In most cases, if an extensive procedure is at all feasible, the
situation will require nothing short of a subtotal or total gastrectomy,
leaving the fundus if the tumor occupies the antrum or the distal part of the
corpus, and leaving the antrum when the tumor is confined to the
most proximal gastric
regions.
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| Plate 4-66 PARTIAL GASTRECTOMY AND BILLROTH ANASTAMOSES |
The surgical
procedure of choice for a gastric or duodenal ulcer is a subtotal
gastrectomy, by which two thirds to three quarters of the distal portion of
the stomach is removed, aiming to reduce the acid-secreting mucosa to such a
degree that the gastric juice reaches a state of anacidity or at least
hypoacidity. Because only complete removal of the entire antrum can guarantee a
permanent ablation of acid production, the distal line of the resection must
lie beyond the pylorus.
The Viennese
surgeon Billroth was the first to perform a partial gastrectomy, which included
the pylorus and connected the distal end of the remaining stomach with the open
end of the duodenum. The mobilization of the duodenum, necessary for such an
end-to-end gastroduodenostomy, can often be obtained tension-free without
technical difficulties. This type of operation, known as the Billroth I
procedure, deserves preference over all other operative procedures, because with it the physiologic
pathway for food transport is preserved and the sequence of the digestive
processes is less disturbed than with any other procedure. Execution of the
Billroth I procedure, however, is restricted by the prime necessity of a
healthy duodenal cuff wide enough for the end-to-end anastomosis. Consequently,
this type of operation is technically precluded, in many cases, by fibrotic or
scarring alterations of the duodenal wall.
Faced with
cases in which the first type of procedure was not feasible, Billroth developed
another type of gastrectomy, known as the Billroth II procedure, in
which, after closing the duodenal opening, he connected the stump of the
stomach to a loop of jejunum. Such a gastrojejunostomy can be constructed
either in front of the transverse colon or in retrocolic fashion, by pulling
the needed length of the jejunum upward through a slit made in the transverse
mesocolon. In the antecolic procedure, it has proved imperative to provide a
side-to-side anastomosis of the afferent to the efferent limb of the jejunum at
some distance from the stomach. This Braun anastomosis prevents stasis
in the afferent limb of the loop and, thereby, the danger of a blowout of the
bypassed duodenal stump.
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| Plate 4-67 |
Bilateral vagotomy
(i.e., the severing of both vagus nerves at the level of the juxtacardial
portion of the esophagus) aims at eliminating or reducing the cephalic phase of gastric
secretion. The hopes once entertained that this simple procedure would
permanently cure an ulcer have not been fulfilled. As experience has shown, the
effect of vagotomy on acid production is often inadequate and, in most cases,
only transient. Furthermore, this severance of the nervous pathway tends to
induce a persistent pylorospasm and dyskinesia of the small and large intestine,
resulting in a severe spastic constipation. If vagotomy is performed as the
sole procedure to relieve ulcer symptoms, because for one reason or another the
surgeon cannot carry out a subtotal gastrectomy, it is always imperative to
perform at least a gastrojejunostomy or pyloromyotomy to prevent a hold-up of the gastric
evacuation.
