Excluding Cases Subjected to Elective Surgery in the Period). From Martin and Lewis (1949). Deaths from haemorrhage . Deaths from perforation . Gastric Ulcer.
The Transactions of the
Medico-Chirurgical Society of Edinburgh THE SURGICAL TREATMENT OF PEPTIC ULCER By A. G. R. LOWDON, ?tBvE.,.JYLA., F.R.G;S.E. From the Department
of Surgery, University of Edinburgh
Introduction
It is
that in the not-too-distant future we shall know enough to cure or at least to control it without Unfortunately we are still very ignorant about the disease. We do not understand the aetiology, and in any individual patient we are unable to make a reliable prognosis about the disease or its complications. In the circumstances we work empirically. To add to our difficulties we find that it takes ten years
hoped
about peptic ulceration to be able the use of surgical measures.
to assess the value of any nor nor
the
description
diathesis, be
new palliative measure?for neither physicians experimentalists have yet produced anything deserving
surgeons
and
"
not
cure."
When the
cure
the ulcer, or the much shorter time.
simply
which removes the ulcer is found, it will doubtless
acid,
in a In the circumstances it is not surprising that our methods of treatment vary almost from year to year, and from medical centre to medical centre. Nor is it surprising that we find it difficult to define categorically the role that the surgeon should play in the treatment of ulcer. Yet the same circumstances make it important that we should frequently review our knowledge and experience, and assess the comparative success of various methods of treatment. This is the justification for a
recognised
statement
about the treatment of peptic ulcer out of date in a few years' time.
"which may be Read J8th
at
January
a
Meeting
1950.
of the
by surgical
Medico-Chirurgical Society
of
measures
Edinburgh
on
A.
2
G. R. LOWDON
The Indications
Surgical Treatment
for
All will agree that the treatment of peptic ulcer should in the first instance be medical, but that operative measures are at present required for the relief of some and even to save the lives of others suffering from the disease. The presence of some complications of ulcer such as or organic stenosis may make surgical intervention essential, but when the chronic ulcer is not attended by any compelling complication the decision for or against surgery is more difficult. It is this uncomplicated type of case that we can most profitably consider
perforation
closely. problem may be morbidity and mortality more
stated simply. It is to weigh the probable of the disease if treated medically against the risks of death from operation and of post-operative morbidity if treated surgically ; but the answer in the individual case is often very difficult for the reasons we have considered. The
In
a
disease with
uncertain
so
a
course
and
prognosis
we
must
its merits, and statistics are of limited judge value. They are not, however, useless, and we may take the problem first from the statistical aspect. each individual
case
on
Ten year follow-up observations on medically treated cases are to find but the literature provides, for example, these figures in series where the follow-up time varies from seven to fourteen years. difficult
TABLE I
Results
of Medical Treatment of Patients with Peptic Ulcer Admitted to Hospital, with Follow-up of Seven to Fourteen Years. Gastric Ulcer.
Percentage
Total Cases.
152
80-3
230
192
Total Cases.
Qvigstad
and Romcke
(1946)
Malmros and Hiertonn Martin and Lewis
(1949)
(1949)
.
Combined results Total number of
cases
of
?
Duodenal
"
Unsuccessful.'
Ulcer.
Percentage Unsuccessful."
88-7
63-S
495
71-0
123
50-0
62
61 *o
467
63-0
787
75'6
peptic ulcer
=
1254 ; Percentage
"
unsuccessful
1
"
=
71 -o.
It is even more difficult to obtain an estimate of the mortality directly due to peptic ulcer which may be expected within ten years if the patients are treated medically. A recent paper by Martin and Lewis (1949) provides valuable information. It is to be noted that the figures I have abstracted provide a conservative estimate of the mortality because of the exclusion of some patients who, because of relapse, were treated by surgery during the ten-year period.
THE SURGICAL TREATMENT OF PEPTIC
ULCER
TABLE II
Mortality
Directly Due to Ulcer during Ten Years after Medical Treatment Cases Subjected to Elective Surgery in the Period). From Martin Lewis (1949).
(.Excluding and
Duodenal Ulcer.
Gastric Ulcer.
Total Cases.
Deaths
from
haemorrhage
Deaths
from
perforation
.
.
Total number of
In
cases
of
Per
cent.
Per
Total Cases.
cent.
231
4-0
105
5-o
231
II-O
I05
9'5
peptic
ulcer
=
336
; deaths =15-0 per cent.
for a comparable estimate of the results of surgical should take gastrectomy as the operation of proved we find that few ten year follow-up reports of the results ?f this treatment have been published, and some of those available include resections which would now be considered to be inadequate
looking
treatment we value. Again ln extent.
Heuer (1944) provides a figure collected from the literature 5 7 cases of gastrectomy for ulcer, all having been followed for rnore than five years and nearly half for more than ten years : of this " total 24 per cent, were considered unsuccessful at the time of 12
"
follow-up.
I think that 24 per cent, of unsuccessful cases is an unduly pessimistic figure because it includes a higher incidence of anastomotic ulcer than ?ccurs with the larger resections now commonly practised. It is now agreed that stomal ulcer follows Cent. of cases.
adequate
resection in less than
2
per
The operative mortality of partial gastrectomy
was at first high, in reports now being published it is commonly less than 3 per cent. and sometimes less than 1 per cent. We should not at present expect sUch results from a surgical clinic where operating is being done by furgeons of varied experience, more particularly if the cases treated delude a proportion of bad surgical risks. In Sir James Learmonth's Urilt in the Royal Infirmary of Edinburgh we have had 144 partial
but
gastrectomies for ulcer in the last two years with 11 deaths (= 7-6 per Cent.) but there is evidence that the mortality is falling. We must add to the operative mortality the late mortality due to recurrent ulcer or complications of the operation occurring within ten years. Heuer has given his combined operative and late mortality as 7*7 per cent. I think we
may estimate the
from reasonably experienced
operative mortality
now
to
be
expected
surgeons at 5 per cent. ; and, if the lricidence of stomal ulcer is under 2 per cent., an estimate of 2 per cent. f?r late mortality is generous to cover all contingencies. If these figures are accepted even as approximations, the balance ls
distinctly chir.
in favour of surgery. a 2
A. G. R. LOWDON TABLE III
Results to be
Comparison of Operative
Treatment
Expected in Ten-Year Period from Medical and (by Partial Gastrectomy) of Peptic Ulcer "
Unsuccessful per cent.
"
Total Mortality per cent.
Medical treatment
71-0
I5-0
Partial gastrectomy
24-0
7*o
Two comments must be made on this comparison. Firstly it must be remembered that the figures refer only to patients admitted to hospital : no account is taken of the large numbers who are treated
medically by their Secondly, it is
doctors
own
hospital out-patients.
or as
consider the relative morbidity in each of the group. The majority of the failures treatment are of medical patients suffering from intermittent ulcer and still exposed to the dangers of complications of ulcer. dyspepsia "
most
unsuccessful
"
significant
to
cases
living as chronic invalids. The full misery of severe not always appreciated even by the patient himself ulcer dyspepsia has he because forgotten what it is like to be well. The only adequate of the morbidity of the disease is the joy and gratitude measurement ulcer of the chronic patient who has (by operative treatment) been made meals. normal a fit man, eating the other hand On only a small proportion of the unsuccessful cases in the surgical group are suffering from incapacitating symptoms. Many
of them
are
is
"
"
A very few have recurrent ulceration : the remainder have one or other of the more severe forms of post-gastrectomy disturbance. These are, with few exceptions, disabilities so mild that description of them is elicited only by leading questions and they are almost invariably
infinitely preferred by ulcer dyspepsia.
the
patients
themselves
to
the
pre-operative
These statistics are, as I have said, only a background to our consideration of the treatment of an individual patient. They suggest that a patient with ulcer disease severe enough to lead to his admission to hospital has, statistically and in the long view, a better chance of life and health if treated by surgery ; but they are far from proving that all cases admitted to hospital should be treated by operation. In our It remains to consider each individual case on its merits. and these merits are a about large prognosis aetiology ignorance "
"
number of features or factors which we know from experience to affect the issue?each one to an uncertain degree, but taken together adding up to a decision for or against surgery : I believe, at present, for surgery in a majority of the patients admitted to hospital with peptic ulcer. I think the factors that must be considered can be conveniently grouped under the following headings : The situation and character
THE SURGICAL TREATMENT OF PEPTIC ULCER
5
the severity of ?f the ulcer ; the response to medical treatment; and social economic the of the and sex the ; symptoms ; patient age factors ; the psychological factors ; concomitant organic disease ; secondary (anastomotic) ulcer ; complications of ulcer : perforation, cicatricial stenosis, fistula, haemorrhage. In order
gastro-jejuno-colic briefly I must be somewhat dogmatic. The situation and character of the tilcer.?Gastric ulcer always carries with it the danger of malignancy : when the symptoms have been present for a comparatively short time in a patient over middle age, the clinician can rarely be certain that the ulcer is simple, and even when there is a long history of typical ulcer symptoms there is danger that cancer has developed in the ulcer?a development which may be rare but certainly does occur. If there is any doubt from clinical ?r radiological features or from failure to respond rapidly to medical treatment that the condition is surely simple, resection should be advised. Duodenal ulcer is not complicated by the risk of malignancy but in considering the pathology of the lesion, whether duodenal or gastric, ^e should also weigh the features of chronicity and evidence of
"to review these
When chronic penetration of other organs such as the pancreas. ulceration has been present for ten years or more and particularly "When there is reason to believe that a posterior ulcer is penetrating the pancreas, the physician is, I think, fighting a losing battle. It is ^rue that intensive therapy may make even such ulcers heal, but they
seldom
remain healed. The response to medical treatment must often be considered. Gastric ulcer responds less satisfactorily to therapy than duodenal ulcer and ln most cases recurrence after effective treatment should lead to Operation. It is relevant also that the results of surgical treatment gastric ulcer, if carried
satisfactory.
out
before
complications arise,
are
particularly
physician is justified in being more persistent, is a patient who has adhered to reasonable diet three or prognosis. If relapse occurs within two
In duodenal ulcer the
but any relapse in
a
of bad Months of effective treatment and if the symptoms are severe, I think the physician should be seriously discouraged. The severity of symptoms may be a significant feature at other times. Sometimes pain is so severe and persistent that the patient limited experience this has In demands
Earning
Practically ?ccurred
more
my operation. of psychological make-up good patients
often in
than in
be refused. poor types, and I believe that such a demand is seldom of ulceration In other cases severe vomiting with each exacerbation ls due to spasm and oedema without cicatricial stenosis, but its ?ccurrence may make the attacks of dyspepsia so incapacitating and that it becomes an indication for surgical relief. to
debilitating
-f?r
of the patient have little bearing on the decision the choice of surgical surgery though much influence on
The age and
or
against
sex
A.
6
G. R. LOWDON
Peptic ulcer may be a severe and dangerous disease at in both sexes and the indications for surgery should be any age considered with little reference to these factors. It is true that in the older patient the disease is sometimes growing less active, but I have been impressed by the fact that ulceration which starts for the first procedure.
a patient over 50 years of age may be fierce and dangerous. The economic and social factors necessarily play a large part in come to terms The professional man may be able to our decision. with his ulcer without detriment to his work ; the same is often true of the woman engaged only in housework. But the labouring man frequently cannot or will not adhere to his diet and do his job. Nor
time in
"
forget the penalty that may fall on wife and children from irritability of a dyspeptic husband and father, or his loss of earning
should the
"
we
power.
Psychological factors are usually present. They must be estimated so far as possible treated, but they will seldom prove a contraindication to surgery, even for the uncomplicated disease, if this is indicated by other features. Even the psychiatrists cannot cure peptic ulcer ! Operations for uncomplicated ulcer should be avoided in the psychoneurotic patient if possible, but even in such a patient the complications of ulcer may require surgical treatment. Concomitant organic diseases must also be weighed in the balance, but are not always contraindications to surgery. They have to be as to the operative risk. considered especially Gastrectomy adding in bronchitic or arteriosclerotic patients is often advisable. Recently a gastrectomy performed by Sir James Learmonth on a patient with active pulmonary tuberculosis was proved by the outcome to be the measure which enabled the patient to overcome his pulmonary disease. Secondary (or anastomotic) ulcer, whether following gastroenterostomy or partial gastrectomy, is in itself a warning that the patient has a severe ulcer diathesis. It is less responsive to medical treatment than primary ulcer and it is a more dangerous lesion because complications are more frequent and more severe. If chronic, it should be treated without delay by surgical measures, and if recent, only one relapse after medical measures should be allowed before the surgeon and
is called in.
Finally the presence of any of the complications of ulcer may decide the issue. Free perforation is to be taken as an indication for immediate operation. Reports of cases of perforation treated conservatively are interesting?and valuable in showing what can be done in circumstances
in snow-bound cottage where operative treatment must be delayed. But early operative closure is still to be preferred. On the continent of Europe perforation is now frequently treated by immediate gastrectomy. This is partly an economic rather than a surgical development, and in Britain this as on
is
not
board
ship practicable
practice
a
is seldom
or
or
regarded
with favour.
SURGICAL TREATMENT OF PEPTIC ULCER
THE
7 "
Recurrence of symptoms after one perforation or after a leaking ulcer treated conservatively is to be regarded in most cases as a development weighing heavily in favour of an elective operation. "
"
Cicatricial stenosis?" hour-glass stomach complicating gastric " as a result of duodenal ulcer?can be ulcer or pyloric stenosis "
relieved
only by operative measures. Gastro-jejuno-colic fistula is another imperative indication for surgery. A patient with fistula may be very ill and definitive surgery is often inadvisable until his general condition has been improved by a preliminary (first stage) procedure. Various first-stage operations have been advised. We have found that a proximal colostomy is both safe and remarkably effective in relieving the distressing symptoms of the condition. an ulcer is the most difficult of the complications be considered from two points of view : firstly as a cause of death and a possible indication for emergency surgery ; and secondly as a feature suggesting the need for elective surgery if and when the patient recovers under medical treatment.
Hemorrhage
to assess.
from
It has
to
growing tendency in recent years for the worst haemorrhage to be treated by immediate gastrectomy. This !s a rational development and has been delayed by the facts that the can seldom be effectively arrested by any operative measure bleeding less formidable than gastrectomy, and that surgeons, more particularly those who habitually deal with emergencies, had insufficient experience of this operation. The mortality of massive haemorrhage under medical treatment is high in elderly patients, and it is clear from many reports that the judicious selection of cases for urgent operation can lead to better results. It is less evident which cases should be so treated, but two governing principles are already clear. Firstly it must be known with reasonable certainty that the gastroduodenal bleeding is due to chronic peptic ulceration. Secondly the decision to treat by operation should not be delayed. The very factors which weigh in favour of emergency surgery have the effect, if persisting, of making the patient a poor operative risk after twenty-four hours and a very bad operative risk after forty-eight There has been
a
cases of
hours.
The operative mortality of emergency gastrectomy will depend entirely on the type of risk accepted for operation, but in all events must be higher than that of interval gastrectomy if the bad risk cases are included. In our wards in the Royal Infirmary we have in the last
three
of
ulcer
by emergency operation 33 per cent, in cases selected as desperately ill. In two of the fatal cases massive haemorrhage from gastric ulcers had followed unrelated major surgical procedures. I feel confident that we can on this figure if given the opportunity improve years treated 9
^ith 3 deaths.
to treat more
cases
This is
cases
a
bleeding mortality of
earlier.
The results of medical
treatment in younger
patients
are
so
good
8
G. R. LOWDON
A.
surgical measures are not justified unless haemorrhage persists haemorrhage recurs under treatment. It should, however, be possible to select from the older age groups a type of patient for whom the prognosis would be improved by immediate operation. The published figures of the mortality of haemorrhage under medical
that or
massive
from i per cent, to 40 per cent. Heuer collected reports from the literature with a mortality of 13-3 per cent., and this may, I think, be accepted as a reasonable average. The medical results which immediately concerned us, however, The physicians in were those in the Royal Infirmary of Edinburgh. treatment vary
of
3063
cases
charge of wards there have courteously allowed us to study their results in cases of bleeding ulcer. The following preliminary review of 200 cases of bleeding peptic ulcer represents the results during the years
1946-49
in 8 of the
12
medical wards in the
hospital.
TABLE IV
Two Hundred Cases of Bleeding Peptic Ulcer Treated Medical Measures Deaths.
No. of Cases.
Duodenal ulcer
115
.
Gastric ulcer
56
Site
21
not
stated
Gastro-jejunal
ulcer
Total number of deaths
These results are, I It is
important
to
by
=
13 ;
mortality
=
6-5
per cent.
you will agree, a credit to the physicians. the period under review about have been referred by the same medical units
am sure
note
that
during
5 per cent, of all cases for emergency surgery. Eleven surgeons, with two deaths.
cases
in all
were so
treated
by
various
the present position by operating clearly be selected with care. In study of these 200 cases we have been surprised to find no evidence of correlation between mortality and previous or repeated haemorrhage. The only significant correlations are with age and severity of haemorrhage as evidenced by signs of shock on admission.
on
If the surgeons are more cases, these
to
improve
cases
on
must
TABLE V
Two Hundred Cases
of Bleeding Peptic
Ulcer.
Mortality
Related to Age Age.
Under 50 years
Total.
110
51 to 60 years
.
Over 60 years
.
Died.
o
47
3
43
10
THE SURGICAL TREATMENT OF PEPTIC
ULCER
TABLE VI
Two Hundred Cases
of Bleeding Peptic Ulcer. Mortality Age and Degree of Shock Total.
Age
over
50 years and shocked
.
Age
over
60 years and shocked
.
I
Related to
Mortality.
67
Died 13
32
Died 10
?
=
19-4 per cent. 31-0 per cent.
that these
figures will persuade the physicians that some is still desirable and possible. I must point out, however, improvement that 5 of the 10 deaths in patients over 60 years of age were in patients who were admitted more than two days after haemorrhage started, and hope
some of these nearest
we
Those
to
present
a
under 50 years who continue to bleed or have of massive haemorrhage under treatment (a group
patients
already, 11 cases
Those
risks. I think the definition of the cases suitable
prohibitive surgical
:?
recurrence
(2)
at
come
for emergency is
(1)
doubtless
were
can
it appears, being referred for surgery because 5 of the treated by urgent operation were in this category) ; and
patients
cent,
or
over 50 years who have haemoglobin under 50 evidence of hemorrhagic shock in low blood
per pressure on admission and who have bled be reasonable surgical risks. For the
recently enough
to
the
general practitioners to send to hospital as quickly as Possible. Perhaps to help them a flying squad with blood transfusion equipment should be organised to bring the more severely shocked rest we must
elderly patients Patients
to
depend
on
who have haematemesis "
"
the wards.
In the
patients who recover from haemorrhage under medical the second consideration arises : is the haemorrhage to be regarded as an indication for elective surgery ? Bleeding is usually, J think, a grave feature in prognosis ; second and subsequent If the haemorrhage is from an ulcer are even more so. treatment
haemorrhages
known
to be chronic and penetrating, it is the more likely to recur. ^ think that recovery from two large haemorrhages should indicate at surgery any age and that recovery from one large haemorrhage in Patients over 45 years is warning enough.
If I
describe the import of all the considerations assessing the condition of the individual patient, I apply would say that I believe it possible in most cases to make a judgement ?f the severity of the chronic ulcer diathesis, and that where one or more of the features described have shown the patient to suffer from a severe or dangerous form of the disease, surgical treatment should be
that
were to
we
recommended.
in
try
to
A.
IO
G. R. LOWDON
The Choice
of
Operation
consider the choice of operative Gastro-enterostomy has recently fallen into It remains
procedure. disrepute because of of anastomotic ulcer after a period when this almost indiscriminately. It should certainly be
to
the high operation
incidence was used avoided for gastric ulcer in all
and for duodenal ulcer in younger that it is the operation of choice for patients. I believe, however, cases. few It in a is much safer than gastrectomy and duodenal ulcer if the relief complication of stomal ulcer can be avoided. gives complete cases
The type of patient in whom there is minimal risk of stomal ulcer and for whom gastro-enterostomy is indicated is the older patient in whom the ulcer diathesis is growing less active and some degree of pyloric stenosis has occurred. There is much less danger of stomal ulcer in women than in men. Partial gastrectomy is, in the present state of our knowledge, the only operation of established value for all other cases of peptic ulceration. The technique usually employed is some modification of the
Polya operation
retrocolic, with
:
whether the anastomosis should be antecolic
or
without valve, are technical problems under debate. At least two-thirds of the stomach should be resected. A gastric ulcer must be included in the resection, but I believe that it is unor
necessary and often inadvisable to attempt to remove a duodenal ulcer unless the operation has been undertaken
posterior to
arrest
hsemorrhage. The great disadvantage of the operation is the relatively high which still attends it, but there is no doubt that this is falling
mortality steadily.
Much attention has
recently been directed to the postoccasionally incapacitating. Our experience is that the only common complaint is a feeling of fullness after meals : this is easily controlled by limiting the quantity eaten The at one time and it usually passes away after a few months. vasomotor disturbances which have been called dumping are rare True hypoglycemic phenomena and very seldom incapacitating. or more after a meal are even less common, and hours two occurring when they do occur are infrequent in the experience of any one patient. In about 150 cases of gastrectomy I have found only two men who are incapacitated for work by post-gastrectomy upsets : both show evidence of psychoneurosis and had not been able to work for a long time prior to operation. In short, the post-gastrectomy syndromes are usually trivial discomforts and even the few patients severely affected much prefer the new discomfort to the previous ulcer dyspepsia. I would like to put in a word for the Billroth I operation which has been somewhat neglected in this part of the country. It is seldom a suitable procedure for the treatment of duodenal ulcer because of the difficulty and danger of using the duodenum for anastomosis in these cases, but in the treatment of gastric ulcer it can be a perfectly gastrectomy syndromes which
are
"
"
THE SURGICAL TREATMENT OF PEPTIC ULCER
II
adequate resection, particularly if combined with the Schiimaker modification. It avoids the dangers of a closed duodenal stump and of a gastro-jejunal anastomosis above the transverse colon. From our experience of this operation it is clear that it is rarely, if indeed ever, followed
Vagotomy
ulcer
"
by is
at
"
or other post-gastrectomy discomforts. present in fashion in the treatment of duodenal
dumping
but the fashion may be said to be passing. Even short term records suggest that vagotomy alone is, on balance, unsatisfactory as a treatment of uncomplicated duodenal ulcer. Though :
follow-up
Producing dramatic immediate relief it does recurrence and it is sometimes followed
combined with gastro-enterostomy may be assess this measure we must await longer
eructations.
Vagotomy successful, but to
more
follow-up
reports than
are
at
present available.
however, to be the treatment of choice gastro-jejunal ulcer after partial gastrectomy, and
Vagotomy Patient with
enterostomy
for the
appears,
should also be used in the ls
not always ensure against by distressingly offensive
in older and
that it entails
I think
of stomal ulcer after gastropatients. Its main disadvantage
treatment
poor-risk
small risk of troublesome and persistent diarrhoea. An alternative which has appeared worth trial is division of the Vagus nerves along with resection of the distal part of the stomach?? a
resection
hormone.
a
designed
to remove
the
area
believed
the
to secrete
gastric
In this way we may remove both the nervous and chemical stimuli to secretion of hydrochloric acid. In the last two years I have treated 41 patients with duodenal ulcer by this procedure which ^e call There has been one death. vagotomy and antrectomy." "
Review
of these
cases
shows that post-gastrectomy upsets are not common or severe than after more
avoided altogether but may be less radical resections of the stomach. In conclusion I would like
to
make
a
ulcer lri
plea
that
patients
with
peptic
should in future be treated in all hospitals (as they already are some) in wards attended daily by both physicians and surgeons can thus co-operate from the time of the admission of the patient making the difficult assessments and decisions that we know to be
^ho
ln
recluired
in such
cases.
REFERENCES
Heuer,
G.
J. (1944),
The Treatment
of Peptic
Ulcer.
London
:
Lippincott.
Malmros, H., and Hiertonn, T. (1949), Acta med. Scand., 133, 229. Martin, L., and Lewis, N. (1949), Lancet, 2, 6590. Qvigstad, I., and Romcke, O. (1946), Acta med. Scand., 126, 34. Discussion 0r
Professor Davidson, opening the
interesting
the
discussion, expressed his appreciation just been given.
and informative papers which had
A.
12
G. R. LOWDON
Professor Davidson noted Dr Card's findings that belladonna in large doses had caused a great reduction in the acidity of the gastric juice. Many years ago, in Aberdeen, Professor Davidson had carefully investigated this problem in cases of peptic ulcer, employing a 24-hour test meal technique He had and using large doses of atropine which produced toxic effects. been unable to show any consistent diminution in gastric acidity. Professor Davidson believed that while sub-total gastrectomy was the answer to the treatment of peptic ulcer under certain conditions at the present time, he felt that a final evaluation of this operation could not be made for another ten years, and then only when the results of a large series of cases had been carefully evaluated by a physician as well as a surgeon. Removal of a large part of the stomach was a most unphysiological procedure which might lead in time to serious effects. Professor Mercer believed that most of these cases were of a highly strung type. For a period of about one year he had invited a psychiatrist to help but the results had been disappointing, and the experiment was discontinued. With regard to operation, Professor Mercer agreed with Mr Lowdon in most of his remarks. There were, however, two points which he would like to
bring (1)
up
:?
He considered it the method
(2)
The
important employed.
appendix, operation.
in his
that
opinion,
a
retro-colic anastomosis should be
should
always
be removed
during
the
With regard to cases of haemorrhage, he maintained that the surgeon should be called in sooner than he usually is?the patient should be under observation of both physician and surgeon from the beginning so that operation could be carried out without delay at the right time. Professor Mercer agreed entirely that gastrectomy was the operation of choice ; it need not necessarily be the formidable procedure that it is so often considered to be. Dr Macleod said he had recently followed up over 150 cases of partial gastrectomy up to a period of five years and believed that there was no doubt that that was the answer to the chronic ulcer. The gratitude of these patients He quoted one case, a young matt) was obvious and touching in its sincerity. a miner, with twelve years history who in that time had lost a considerable amount of working time, but who had resumed work at the coal face one month after operation and had not lost any work since then. His weight and well-being had increased and he was now able to consume as much as 10 pints of beer three times a week. In this group of cases about 60 per cent, had gained weight of up to 3 stones, 25 per cent, had lost weight and the remainder showed practically no change. Capacity for work was not affected. Some had changed their jobs, but he felt that those that did change would have done so in any caseAs regards post-operative complications, roughly 50 per cent, had no complaints and could eat a normal substantial three-course meal with no ill' effects. Of the remainder about half were troubled with epigastric discomfort and distension and the remainder had, in addition, recurrent attacks A " " " " vomiting. These groups he classified as mild and moderate ano though they were perhaps inconvenienced they were not apparently hand*' capped. Of the whole seiies only about 6 per cent, were true dumpers. These .
THE SURGICAL TREATMENT OF PEPTIC
ULCER
13
"
he classified as severe." They were both inconvenienced and handicapped. In view of these complications he suggested that a scholar or team of scholars provided with the nesessary scholarships should follow up all cases of partial gastrectomy carried out in Edinburgh over the past ten or fifteen years. Dr Macleod had been struck at the frequency with which partial gastrectomy had been done and estimated that at least 400 had been performed in Edinburgh last year. With regard to the controversy between ante-colic and retro-colic he felt that it should be settled in favour of retro-colic. Radiologically, at least, filling of the afferent loop was much more common in ante-colic anastomoses. Personally, if he had a troublesome peptic ulcer, he would have a Partial gastrectomy within five years with a retro-colic anastomosis. The size ?f the stoma he would leave to the choice of the surgeon. Dr Douglas Robertson said that the family doctor viewed the problem from a rather different angle. He, of course, sees the cases of chronic ulcer, hut he also has the privilege of seeing many patients in the pre-ulcerative stage, when the X-ray reveals only an irritable, hyperactive stomach, with a spastic pylorus. Many of these persons are likely to develop chronic ulcers not taken in hand.
Dr Robertson considers the psychogenic factor of great importance in the of peptic ulcer. By instruction of the patient in methods of mental and physical relaxation and adequate sedation by means of phenobarbitone 0r sodium amytal a great many of these cases can be prevented from reaching the chronic stage. The pre-ulcerative condition is very common, and the general practitioner has an important role to play in the prophylaxis of chronic ulceration. Mr John Bruce believed that one of the most important developments in the management of diseases of the stomach in recent years was the increasing association between physician and surgeon at every stage of the investigation and treatment. In the Western General Hospital patients with peptic ulceration ^ere, as a rule, assessed by both medical and surgical divisions, many of them 111 a special gastro-intestinal unit conducted jointly by Dr Card and himself. such a unit it was possible to ensure invaluable co-operation both in the Pre-operative and in the post-operative care of patients submitted to surgical
etiology
treatment.
He agreed with Mr Lowdon that, by and large, sub-total gastrectomy operation of choice for gastric and duodenal ulcer in which medical
Was the
treatment
had
desirable.
failed,
or
the
development
of
complications
made
operation
In his unit vagotomy had been tried as an experiment in some 34 patients. In 14 of them no other procedure was carried out and the results, ?n the whole, had been disappointing. In 2 cases ulceration had recurred, and 2 on for had to be re-admitted to
patients account of gastric stasis.
^chequered,
and several had had
nged, difficulty
Esophagus.
hospital
in
gastro-enterostomy
The convalescence from the
swallowing
a
as a
operation
was
not
temporary, but occasionally quite proresult of spasm at the lower end of the
In the remainder of the cases the vagal resection was supplemented by and, in these cases, the results had been gratifying. He gastro-enterostomy ad reserved this procedure particularly for the elderly patient or in those in the technical difficulty of gastrectomy appeared too formidable, ufficient time had not elapsed to indicate whether this combination would nd any permanent place in the surgery of chronic peptic ulceration.
^hom
A.
14
G. R.
LOWDON
large majority of his patients with peptic ulceration were submitted gastrectomy with results which appear satisfactory, although a strict follow-up had not yet been undertaken. During the last year, the gastric resection was a very high one, after the fashion of Visick. There are indications that such liberal resections may lead to nutritional difficulties, and may well prove more extensive than is either necessary or desirable ; but so far he had The
to
not
been
seriously perturbed by post-gastrectomy
states.
Post-operative
uncommon, and he had only encountered it since adopting a dumping valvular type of anastomosis with a small stoma which some had claimed to be the one certain method of avoiding it. For this reason he was doubtful if was
technical variations were of great, or indeed, of any importance. Many, with the recollection of gastrectomy fifteen or twenty years ago, With were apt to regard it as a formidable ordeal of uncertain outcome. modern resources of anaesthesia, chemotherapy, blood bank and the co-operation of the medical members of the team in the after care, the present mortality from the operation was insignificant, and not greater than that of
appendicectomy
in acute
appendicitis.
he would like to
Dr Card and Mr Lowdon disease. Mr J. R. Cameron was in agreement with Mr Lowdon's paper ; the point which impressed him most was the time devoted to the bleeding ulcer. Mr Cameron felt that this was a point where great advances were being made. The question was now being raised as to which side, medical or surgical, these urgent cases should be admitted. He was of the opinion both sides should be consulted. Mr Cameron too believed that at present gastrectomy was the operation of choice. He practiced the Polya retro-colic, lesser to greater curvature anastomosis with a valve, and that even in the bleeding ulcer it was not such It could be less intricate and was much more a formidable affair as formerly. satisfactory than the older transgastric, underrunning, infolding, quadruple ligaturing and similar operations for haemorrhage. Removal of the appendix he regarded as a part of the operation whenever possible, having been faced with cases which had developed acute appendicitis within a year of partial gastrectomy. He referred in this connection to the teaching of Sir David Wilkie on the frequency of the abdominal triad and the frequent coincidental presence of appendicular and ulcer disease. Dr Card, replying, agreed that co-operation between the physician and In
on
conclusion,
their
masterly
surveys of
an
congratulate
important
was increasingly important. As regards belladonna, the dose given was very large and seemed more effective when given orally than atropine parenterally. He did not wish to give the impression that he disbelieved in the importance of psychological factors in the causation of ulcer. Quite the reverse ; he simply wished to make the point that the theory was not modernIn reply, Mr A. G. R. Lowdon said it had been implied, if not actually stated in the discussion, that partial gastrectomy was no longer a formidable operation. He thought it was better to continue to regard the procedure as & difficult and dangerous one which should be avoided if possible and which should be performed only by a relatively experienced surgeon, more especially in emergency cases. A few skilful and experienced surgeons could complete the operation in less than one hour, but most, like himself, took more than one hour and a half. Fortunately modern anaesthesia and intravenous infusion time to be spent without added risk to the patient. allowed this techniques
the surgeon
THE SURGICAL TREATMENT OF PEPTIC
ULCER
15
He did not
remove the appendix as a routine but only when there was evidence of previous inflammation and when the removal could be accomplished without technical difficulty from the upper abdominal incision. In conclusion he would like to say that in trying to present this difficult subject briefly he had made some statements with more apparent confidence than he felt, and that his advocacy of gastric resection was made with acute
some
awareness that the
something
chir.
operation
was a
better could be offered.
mutilating
one, to be tolerated
only
till
