Billroth I Resection for Peptic Ulcer PAUL W. JOHNSTON, M.D., Los Angeles. and JOSEPH A. WEINBERG, M.D., Long Beach

THE BILLROTH I gastric resection for peptic ulcer * The Billroth I gastric resection, with and with- has been used with increasing frequency in recent out vagotomy, was used in 20 selected cases of peptic ulcer. years in spite of the prejudice of many against the Vagotomy and pyloroplasty is considered the procedure. Bohmansson2 3 of Sweden has renewed operation of first choice for duodenal ulcer. The the interest in the operation. In America, Clagett, cases for Billroth I resections were selected from Waugh and Higgenson4 12 advocated its use for cases not suitable for pyloroplasty. gastric ulcer, and Harkins and associates'5 extended Operations for peptic ulcer which preserve the gastrointestinal continuity are considered to be its application to include duodenal ulcers as well. physiologically superior. Vagotomy and pyloro- Other surgeons, among them Kocher,13 von Hab- plasty, and Billroth I gastric resection both qual- erer,9 Finney,8 Schoemaker23 and Polya,'9 through ify in this regard. The postoperative digestive the years since Billroth first described the procedure symptoms after Billroth I gastric resection in the in 1881, have favored its use, although standing present series were minimal, which tends to con- alone among their contemporary surgeons. firm this theoretical superiority. This report will relate the experience with Billroth I gastric resection at the Veterans Administration however, expressed belief that antral function may Hospital, Long Beach. Since April 1954, 20 patients be the determining factor in gastric ulcer. (3) The have had a Billroth I gastric resection, either alone intestinal phase is generally considered to have little or in combination with vagotomy. The rationale of part in the production of peptic ulcer. Recently the procedure will be discussed, and data on the Porter, French and Movius,20 described a late ceph- indication, technique, morbidity, mortality, and alic phase mediated through the pituitary-adrenal early results in these cases will be given. axis. Its role in the production of ulcer is uncertain; Surgical operation for peptic ulcer aims to alter it may help to explain the occurrence of ulcer in the stomach physiologically in such a way as to association with corticosteroid therapy. afford protection against recurrence of disease and Good digestion depends primarily on the func- still maintain good digestive function. Overruling tion of the stomach. The stomach acts as a reservoir these considerations is the fact that the alteration for ingested food. It corrects the temperature and must be done with safety to the patient. Balfour' tonicity of this food by its rich vascular supply and brought out these points very well in an editorial in abundant secretions. By means of its heavy muscu- 1934. lature it triturates the food, and mixes it with the Acid-pepsin secretion is in general controlled by gastric enzymes. With antral contraction, the pylorus three factors. (1) The cephalic phase is mediated relaxes, and a small amount of chyme passes into through the vagus nerve. The importance of acid- the duodenum. Thus the small bowel receives a pepsin secretion due to vagal hyperfunction in prepared material, one which is of the correct tem- human beings, particularly the importance of the perature, is isotonic, is triturated into small particles, nocturnal hypersecretion, has been clearly shown by is partially digested, and is delivered in small Dragstedt.5' 6 (2) The gastric phase is mediated amounts.'4 through gastrin, a hormone which is produced in Digestion depends further on the supply and ade- the antrum, mainly in response to mechanical dis- quate mixing of the pancreatic, hepatic and intestinal tention. Animal experiments on the dog with iso- secretions with the chyme; of these the pancreatic lated gastric pouches and transplanted antrums, in secretions are the most important. Secretin, a hor- the laboratories of both Harkins22 and Dragstedt,7 mone which is produced for the most part in the pointed to the great importance of antral function duodenum as a result of the presence of chyme, is in producing ulcer. Whether these results can be the most important factor in stimulating pancreatic related to human beings is uncertain. Dragstedt, secretions. The secretion of bile and succus entericus comes about mainly as a result of stimulation of the From the Surgical Service, Veterans Administration Hospital, Long Beach. duodenum by chyme. Presented before the Section on General Surgery at the 84th Annual All gastric operations for peptic ulcer alter in Session of the California Medical Association, San Francisco, May 1-4, 1955. some fashion and to variable degrees the acid-pepsin VOL. 84. NO. 3 * MARCH 1956 157 TABLE 1.-Nature of disease In 20 cases In which Bilroth I operation was done Billroth I gastric resection was chosen in these cases because of certain advantages:' Actively bleeding duodenal ulcer.------6 1. The entire surgical procedure 4is.perfoervd Gastric ulcer ..6 in the supracolic compartment. The mesocolon is Concomitant gastric and duodenal ulcer ..4 Actively bleeding gastric ulcer...... 1 undisturbed, and the danger of inadvertent injury Obstructed duodenal ulcer...... 1...... 1 of the middle colic vessels is less and the possibility Jejunal ulcer, following vagotomy and for a postoperative internal hernia into the lesser gastroenterostomy...... 1...... 1 Duodenal ulcer, following vagotomy and pyloroplasty.. 1 sac is avoided. There are fewer adhesions below the mesocolon, and thus the danger of a postoperative 20 intestinal obstruction is less. 2. The danger of a blow-out of the duodenal production of the stomach and the digestive func- stump, which is a dreaded and often fatal compli- tions of the stomach and intestines. The ordinary cation of the Billroth II gastric resection, is avoided. Billroth II gastric resection removes the antrum and 3. The procedure can be performed more easily a considerable part of the acid-pepsin bearing por- and more rapidly than a Billroth II gastric resection, tion of the stomach. It depends entirely on the com- for there are fewer technical steps. pensatory ability of the intestine to make up for 4. The possibility of obstruction of the efferent disturbances in digestion. The Billroth I gastric re- limb of the gastrojejunal anastomosis due to kinking section aims to disturb the digestive function as is obviated. The occurrence of a gastrojejunalcolic little as possible. In this connection Harkins and fistula is also obviated. co-workers10 recently suggested a combined physi- 5. The normal continuity of the gastrointestinal ological operation for peptic ulcer, one that would tract is maintained. The presence of chyme in the provide maximal alteration of the factors controlling duodenum produces maximal stimulation of secre- acid-pepsin production and minimal alteration of tin, the most powerful stimulus for the production the factors controlling digestion. The proposed oper- of bile and pancreatic secretion. Duodenal exclusion ation was vagotomy, antrectomy and gastroduoden- as with a Billroth II gastric resection interferes with ostomy. this mechanism. The maintenance of normal con- At the Veterans Administration Hospital at Long -tinuity also promotes thorough mixing of the food Beach, vagotomy and pyloroplasty is the operation with the bile and pancreatic juice. of first choice for duodenal ulcer. It meets the 6. The gastric remnant empties more slowly after criteria of Balfour very well. It is a safe operation, a Billroth I procedure. This may be related to the a point which has not received due emphasis in the production of enterogastrone, which inhibits gastric current discussions on the surgical management of motility. This hormone is produced in the duodenum peptic ulcer. The mortality rate in some 800 vagot- in response to the presence of fat. Bohmansson ex- omies was 0.5 per cent. The recurrence rate of ulcer pressed belief that this delayed gastric emptying is after the operation is low-about 6 per cent. If only the most important factor in preventing the dump- definitely proved recurrences are tabulated, the rate ing syndrome. is 3 per cent. The incidence of severe postoperative 7. The duodenum offers more resistance to re- digestive disturbances is also low, about 5 per cent; current ulceration than does the jejunum.11 Further- two-fifths of these are attributed to emotional fac- more the duodenum in response to the presence of tors, and three-fifths to organic digestive factors, chyme produces a factor that inhibits gastric acid such as the dumping syndrome, diarrhea or gastric production.18 Both of these factors should play a retention. Gastric retention is a minimal problem, role in preventing recurrent duodenal ulcer after a for pyloroplasty affords good drainage of the stom- Billroth I gastric resection. ach after In the overall evaluation of vagotomy.27 8. The maintenance of the continuity of the the late results of vagotomy and pyloroplasty, it intestinal has been noted that a very satisfactory result occurs tract provides for utilization of the greatest in 89 cent the absorptive area of small bowel,'for no part of the per of cases.25 small bowel is by-passed. In certain cases, the condi- however, pathologic 9. The maintenance of the normal gastrointes- tion is such that pyloroplasty is not a suitable pro- tinal cedure. In some of these cases at the VA hospital, tract improves metabolic factors, as demon- Billroth I gastric resection was done. The preference strated by better fat and iron absorption, and better for vagotomy and pyloroplasty accounts for the weight gain.28 highly selective nature of cases for Billroth I gas- The more important advantages of the Billroth tric resection. Data on the 20 cases in which this I gastric resection are on the score of less severe and procedure was chosen are given in Table 1. less frequent digestive and metabolic disturbances. 15S8 CALIFORNIA MEDICINE It has been the clinical impression of many sur- culty of stomal obstruction or of leakage has geons, including Bohmansson, Perman,17 Wallen- occurred with this technique. Roentgen studies three sten,24 Clagett, Rauch,21 Harkins, Moore, and months after operation showed complete emptying others that this is so. of the gastric remnant at three hours. There were in addition several special advantages Morbidity with the Billroth I gastric resection for the Billroth I gastric resection in the cases in was minimal. One patient had questionable throm- which it was selected in the present series. For bophlebitis and was treated with anticoagulants. actively bleeding duodenal or gastric ulcers, the Another patient had superficial wound separation Billroth I procedure permits resection, and thereby down to the anterior fascia of the rectus muscle. The gives good control of the bleeding ulcer. It has wound healed by secondary intention. The only com- been noted that a good and safe gastroduodenal plication directly attributed to the procedure was in anastomosis can be made on a duodenum which, if a patient who had severe bleeding from the suture a Billroth II had been done, would have presented line of closure of the lesser curvature of the stomach great difficulty in closure of the duodenal stump, and on the fifth postoperative day. Operation was re- probably would have required closure over an ex- quired to control the hemorrhage. A small incision ternal catheter. For gastric ulcer the resection per- was made and the bleeding vessel was secured with mits submitting the ulcer for immediate pathologic a transfixation ligature. examination. If the frozen section shows malignant The one fatal case in the series was that of a change, or if the permanent sections show malignant patient who died on the eleventh postoperative day disease after the frozen section is interpreted as of pneumonitis and multiple abscesses of the lung. negative for cancer, it is much easier to proceed with He had a carcinoma of the hypopharynx that had radical operation after a Billroth I gastric resection. been previously treated with radiation, and he had It must be conceded that Billroth I gastric resec- great difficulty swallowing. The operation was done tion is not the only way of dealing with these cases. to control bleeding from a posterior duodenal ulcer Vagotomy, pyloroplasty and ligation of the bleeding which had eroded the gastroduodenal artery. The vessel in the ulcer bed has been used with favorable patient did well for seven days after operation. At results,26 and Movius, DaGradi and Weinberg'6 that time he complained of pain in the right hemi- reported on the favorable results of using vagotomy, thorax and became febrile. His condition progres- pyloroplasty and wedge resection of the stomach sively deteriorated until death in spite of all treat- for gastric ulcer. ment. The Schoemaker modification of the Billroth I The early postoperative results were gratifying. gastric resection was used exclusively in the present The Billroth I gastric resection proved to be tech- series. In 11 of the cases the operation was done in nically effective in dealing with the cases for which association with vagotomy. For duodenal ulcer, or it was used in this series, especially in dealing with for concomitant duodenal and gastric ulcer, a vagot- cases of bleeding duodenal or gastric ulcers, and of omy, partial (60 per cent) gastrectomy and Billroth concomitant duodenal and gastric ulcers. The pa- I anastomosis were done. For gastric ulcer alone a tients were studied radiographically and clinically partial (60 per cent) gastrectomy and Billroth I three months after operation. The postoperative anastomosis were done. In the two cases of re- x-ray studies have shown complete emptying of the current ulcer after vagotomy a 75 per cent partial gastric remnant in three hours and no objective gastrectomy and Billroth I were done. evidence of recurrent ulcer. None of the patients No technical difficulties were encountered with complained of recurrent ulcer pain. Complaints of these various degrees of partial gastrectomy. With digestive difficulties were minimal. Three patients mobilization of the duodenum by means of the noted a moderately decreased capacity for food. Kocher maneuver, and mobilization of the greater One had occasional loose stools. One had slight curvature of the stomach to include the short gastric weakness after meals. The most severe digestive arteries, a 75 per cent partial gastrectomy and gas- complaints, consisting of postprandial fullness, nau- troduodenal anastomosis can be done without ten- sea and occasional vomiting, occurred in a 39-year- sion. The addition of vagotomy when it is indicated old woman who had had a previous duodenal- adds to the ease of mobilizing the gastric remnant for jejunal anastomosis to relieve efferent obstruction anastomosis. of a gastroenterostomy. The Billroth I gastric resec- The gastroduodenal anastomosis has been per- tion was done for a bleeding duodenal ulcer, and formed with interrupted No. 50 cotton sutures, two the duodenal-jejunal anastomosis was left intact. rows posteriorly; but only one row anteriorly. If the The patient was well satisfied in spite of the post- cut ends in the stomach and duodenum are different operative complaints, for the disabling ulcer pain in size, the smaller one can be enlarged with an in- was completely relieved. Postoperative x-ray studies cision along the anterior longitudinal axis. No diffi- showed complete emptying of the gastric remnant in

VOL. 84. NO. 3 * MARCH 1956 159 TABLE 2.-Results of Billroth I gastric resection

Case Age and 3-Month Foliowup Weight Since No. Sex Disease Indication Operation Complication Ulcer Pain Digestive Symptoms Operation 1. 60 M Gastric ulcer Suspicion of Gastrectomy 60% None None None No change carcinoma Billroth 1 2. 32 M Duodenal Pyloric Vagotomy Bleeding from None None ulcer obstruction Gastrectomy 50% site of lesser Billroth I curvature closure 3. 61 M Two gastric Gastric ulcer Gastrectomy 60% None None None 3 lb. gain ulcers Billroth I 4. 38 F Duodenal Active Vagotomy None None Moderate postpran- ulcer bleeding Gastrectomy 607c dial distress, nausea, Billroth I occasional vomiting 5. 57 M Gastric ulcer Gastric ulcer Gastrectomy 60% None None None 13 lb. loss Billroth I 6. 65 M Duodenal and Pyloric Vagotomy None None Mild decreased 13 lb. gain gastric ulcer obstruction Gastrectomv 60% capacity for food Billroth I 7. 59 AM Gastric ulcer Active Gastrectomy 60% None None Mild decreased 10 lb. gain bleeding Billroth I capacity for food 8. 31 M Gastric ulcer Gastric ulcer Vagotomy None None None 22 lb. gain and duodenal Gastrectomy 60% scar Billroth I 9. 66 M Gastric and Suspicion of Vagotomy None None None 3 lb. gain duodenal carcinoma Gastrectomy 60% ulcer Billroth I 10. 75 M Gastric ulcer Pyloric Gastrectomy 60% None None Moderate loss of 13 lb. loss obstruction Billroth I strength 11. 43 M Gastric ulcer Gastric ulcer Gastrectomy 60% None None None No change Billroth I

12. 55 M Duodenal Active Vagotomy Death on 11thof postoperativeright lower lobe.day fromPatientmultiplehad ulcer ulcerbleedingleedin, Gastectomy6017cabscessesGastrectomy 60% great difficulty swallowing because of card- Billroth I noma of hypopharynx. 13 47 Ml Duodenal Active Vagotomy None None Mild weakness 16 lb. loss ulcer bleeding Gastrectomy 60% after meals Billroth I 14. 52 M Gastric ulcer Pyloric Vagotomy None None Occasional diarrhea 9 lb. gain and duodenal obstruction Gastrectomy 60% scar Billroth I 15. 23 M Duodenal Active Vagotomy None None Mild decreased No change ulcer bleeding Gastrectomy 60% capacity for food Billroth I 16. 23 M Two duodenal Active Vagotomy None None None No change ulcers bleeding Gastrectomy 60%7 Billroth I 17. 42 M Duodenal Active Vagotomy Superficial None None No change ulcer bleeding Gastrectomy 60%/c wound Billroth I dehiscense 18. 28 M Duodenal Duodenal ulcer Gastrectomy 75%7 None None None No change ulcer after vagotomy Billroth I & pyloroplasty 19. 61 M Gastric ulcer Gastric ulcer Gastrectomy 60% Thrombophlebitis Billroth I ulcer 20. 71 M Jejunal ulcer Jejunalafter vagotomy Gastrectomy 75% None gastroenter- Billroth I ostomy

160 CALIFORNIA MEDICINE three hours. All the rest of the patients were free of 13. Kocher, T.: Mobilisierung der Duodenum and Gastro- symptoms. duodenostomie, Zentralbl, Chir., 30:33-40, Jan. 1903. 14. Mikkelsen, W.: Restoration of esophagointestinal con- It is acknowledged that the period of observation tinuity after total gastrectomy: Physiologic effects, Am. J. of of these patients after operation was too short to Gastroenterology, 21:281-284, April 1954. warrant definitive conclusions. The early results 15. Moore, H., and Harkins, H.: The Billroth I Gastric nevertheless were encouraging enough to merit con- Resection, Little, Brown & Company, Boston, Mass., 1954. 16. Movius, H., DaGradi, A., and Weinberg, J.: Conserva- tinuing the study. tive resection for gastric ulcer, Am. J. Gastroenterology, 1400 North Vermont Avenue, Los Angeles 27. 22:136-141, Aug. 1954. 17. Perman, E.: Dumping Syndrome After Gastrectomy, REFERENCES Acta med. scandinav., Suppl. 196:361-365, 1947. 1. Balfour, D.: The status of Billroth I in the surgery of 18. Pincus, I., Thomas, J., and Rehfuss, M.: A study of the stomach and duodenum, S.G.O., 58:917-918, 1934. gastric resection as influenced by changes in duodenal 2. Bohmansson, G.: On the technique of partial gastrec- acidity, Proc. Soc. Experimental Biol. & Med., 51:367-368, tomy (Billroth I), Acta Chir. scandinav., 75:221-241, 1934. June 1942. 3. Bohmansson, G.: Prophylaxis and therapy in late post- 19. Polya, E.: Reestablishment of the gastrointestinal pas- gastrectomy complications, Acta med. scandinav., 138., suppl. sage after gastric resection, S.G.O., 70:220-290, Feb. 1940. 246:37-45, 1950. 20. Porter, R., Movius, H., and French, J.: Hypothalamics 4. Clagett, O., and Waugh, J.: Indications for and advan- influence on hydrochloric acid secretion of the stomach, tages of Schoemaker-Billroth I gastric resection, Arch. Surg., Surgery, 33:875-880, 1953. 56:750-765, June 1948. 21. Rauch, R., and Reiter, B.: The treatment of post- 5. Dragstedt, L.: Section of the vagus nerves to the prandial distress following gastric resection, Gastroenter- stomach in the treatment of peptic ulcer, S.G.O., 83:547- ology, 23:347-355, 1953. 549, 1946. 22. Sauvage, L., Schmitz, L., Storer, E., Kanar, E., Smith, 6. Dragstedt, L.: The role of the nervous system in the F., and Harkins, H.: The relation between the physiologic pathogenesis of duodenal ulcer, Surg., 34:902-903, 1953. stimulatory mechanism of gastric secretion and the incidence 7. Dragstedt, L., Oberhelman, H., and Smith, C.: Experi- of peptic ulceration, S.G.O., 96:127-142, Feb. 1953. mental hyperfunction of the gastric antrum with ulcer 23. Schoemaker, J.: Zur Technik der Magenresektion formation, Ann. Surg., 134:332-341, Sept. 1951. nach Biliroth I, Arch. Klin. Chir., 121:268-271, 1922. 8. Finney. J.: A new method of gastroduodenostomy, end 24. Wallensten, S., and Gothman, L.: An evaluation of to side; with illustrations, Tr. South. S.A., 36:576-578, 1924. the Billroth I operation for peptic ulcer, Surg., 33:1-20, 1953. 9. von Haberer, H.: Terminolaterale Gastroduodenostomie 25. Weinberg, J.: Vagotomy and pyloroplasty in the treat- bei der Resektionsmethods nach Billroth I, Zentralbl. Chir., ment of duodenal ulcer. To be published in Am. J. Surg. 49:1321-1327, Sept. 1922. 26. Weinberg, J.: Personal communication. 10. Harkins, H., et al: A combined physiologic operation 27. for peptic ulcer, West J. of S. G. & 0., 61:316-319, June 1953. Wilkins, F., Johnston, P., and Weinberg, J.: Pyloro. plasty as a drainage procedure in the vagotomized patient, 11. Harper, F.: Development and treatment of peptic West, J. of S.G.O., 62:525-527, 1954. ulcer; experimental study, Arch. Surg., 30:394-404, 1935. 28. Wollaeger, E.: Disturbance of gastrointestinal function 12. Higginson, J., and Clagett, O.: Gastric resection: The following partial gastrectomy, Postgrad. Med., 8:251-252, Schoemaker-Billroth I operation, Surg., 24:613-620, Oct. 1948. 1950.

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