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.
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.
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.