Postgrad Med J: first published as 10.1136/pgmj.30.348.523 on 1 October 1954. Downloaded from 523

SURGERY OF PEPTIC ULCERATION AND ITS COMPLICATIONS NORMAN C. TANNER, M.D., F.R.C.S. ! Part HI

Post- Conditions year from operation, for the symptoms usually Early post cibal symptoms. I have little to add abate with time and they may diminish even as late to the vast amount which has been written on the as after the third or fourth post-operative years. aetiology of early post cibal symptoms or Flushing and palpitations rarely persist and the 'dumping '-that is symptoms of epigastric symptoms most likely to continue are biliary discomfort, sweating, flushing, palpitation and vomiting, which is not always post-prandial, fatigue, sometimes biliary vomiting, appearing inability to take certain articles of diet with usually shortly after a meal, particularly a heavy comfort, notably milk or egg, and post-prandial meal in patients who have had a gastrectomy. I diarrhoea. Protected by copyright. would, however, suggest that many of the We have used six surgical procedures for symptoms are merely an exaggeration of the persistent symptoms. normal physiological response to over-eating. i. . This was done several years ago The reaction naturally comes sooner in the in the belief that some of the symptoms might gastrectomized, because the capacity for taking have been due to stimulation of vagus nerve food is reduced. Similar symptoms are occas- endings in the suture line. This operation has ionally encountered in persons who have had no produced no benefit in any case (eight altogether). operation, as a form of functional dyspepsia, and 2. Short circuiting the afferent and efferent they may occur in persons who suddenly take a jejunal loops. This is done in the belief that large meal after many hours or days of frugal discomfort is due to stasis of bile in the afferent meals. In prophylaxis, I commend the practice jejunal loop, this belief being supported by the of explanation before the onset of symptoms. relief often obtained when bile is vomited. As the The sudden onset of flushing and palpitation short circuit reduces the volume of biliary fluid during convalescence, shocks the patient and entering the and so increases the risk of http://pmj.bmj.com/ undermines his confidence and leads to ap- stomal ulceration, we usually add a vagotomy. prehension and anxiety. If the patient has been In the earlier four cases a two to three inch long told to expect these symptoms, and reassured that stoma was made, but latterly in two cases we have they will progressively diminish and that they used Steinberg's pantaloon operation, that is do not imply the development of heart or other removing the whole spur between efferent and new trouble-then they are accepted calmly and afferent loops right up to the stomach (Fig i6).

are minimized rather than exaggerated. This operation does diminish biliarv vomiting on September 27, 2021 by guest. In treatment, the patient should be advised to and tlhree of the cases were improved. None were resume normal meals as early as possible in made worse by it. order to hasten the time when the organism 3. Conversion to a Roux type of stoma. In the becomes adjusted to the new state of affairs. A Macarthur Lectures which I had the honour to period of recumbency should be taken if the deliver in Edinburgh in 1951, I mentioned the symptoms occur, and the tea-time meal-the great benefit to be obtained by conversion to a time when dumping is usually first complained of, Roux type of anastomosis when there was severe should be made a small, dry, high protein, high fat biliary regurgitation following end in side meal-e.g., boiled egg, bread and butter with oesophago- after total gastrectomy minimal fluid, or abandoned altogether. (Tanner, I95I). I mentioned a simple method of Certain cases are severe enough to require affecting this (Fig. I7). A similar easy method is further surgical help. for post cibal avaailable following partial gastrectomy,? 1;ut I symptoms should not; be undertaken less than a pointed out that there was a great risk of stomal 524 POSTGRADUATE MEDICAL JOURNAL October 1954Postgrad Med J: first published as 10.1136/pgmj.30.348.523 on 1 October 1954. Downloaded from

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FIG. 17.-Simple methods of conversion of (i) total or (2) partial gastrectomy to a Roux form of anasto- C mosis. (Note.-This diagram was also shown in Edin. med. J3. article.)

ulceration following and that it must be combined with vagotomy or a very high partial gastrectomy made. In a partial gastrectomy which I con- verted to a Roux form combined with vagotomy in 1950, there was no benefit, and I have since converted him to a Billroth I type of anastomosis.http://pmj.bmj.com/ My colleague, Mr. Andrew Desmond, did two others and there is a suspicion of stomal ulcera- tion in both. 4. Capper and Butler (1951) suggest that D dumping symptoms are due to drag on the oesophagus and lesser curve of the stomach by the

weight of the filled stomach and adjacent jejunum, on September 27, 2021 by guest. and suggest stitching up the gastric stump to the left gastric pedicle and to the gastrosplenic omentum, both as a means of prophylaxis and of treatment. We used it nine 'times in prophylaxis, and three times in treatment. One of the latter had temporary relief but relapsed after four months, and two had no relief at all. (Very adequate suspension was later confirmed at a further operation in two cases.) The prophylactic suspension was added in nine cases. Five have FiG. l6.-Operations designed to correct dumping symptoms. B-Conversion to a gastro-duodenal no dumping, two have developed mild post cibal anastomosis. C-Jejuno-jejunostomy. D-The symptoms (one with biliary vomiting), one has 'Pantaloon ' operation. fullness after meals and attacks of diarrhoea and October 1954 TANNER: Surgery of Peptic Ulceration and its Complications 525 Postgrad Med J: first published as 10.1136/pgmj.30.348.523 on 1 October 1954. Downloaded from

CONVERSION TO BILLROTH I FOR DUMPING No. followed-up, three month to four years ...... 21 Very satisfactory ...... 10 Much improved ...... 5 Improved ...... 3 I.S.Q ...... 3 Worse ...... one has late hypoglycaemic-like attacks. These replacement, probably because the reverse peri- symptoms will probably be transitory, but on stalsis of the colonic loop carries duodenal juices the whole, judging by this very small series there into the stomach. Moroney (i -)has mentioned is no great improvement this point. The jejunal loop might be safer if put 5. Although we found the gastro-duodenal in reverse! A third case was one of ' inability to form of anastomosis after gastrectomy to lead to take big meals and loss of weight,' in a woman nearly as many cases of dumping as the gastro- aged 47. She had already had a high Billroth I jejunal anastomosis, they seemed to be less severe anastomosis for gastric ulceration, and this seemed forms. Consequently, since 1948 we have tried as suitable a case as any for enlarging the stomach the effect of conversion from gastro-jejunal to a by the insertion of a jejunal loop between the gastro-duodenal anastomosis in some 26 cases. stomach and . She made a good There was an operative death in a man with recovery but her symptoms remain quite un- mitral stenosis, and one patient died since re changed. turning to his home from pulmonary tuberculosis, This small but interesting series of three cases from which he was known to have suffered shows that jejunal replacement is easy to do but previously. Three have less than three months dangerous in view of the risk of post-operative

follow up, leaving 21 -cases carried out between ulceration. I believe its main benefit is that it Protected by copyright. three months and four years ago. returns the gastric chyme through the duodenum The three patients not improved by conversion again. This can be done more simply by con- to a Billroth I anastomosis included one who had version to a Billroth I operation. previously had a Roux operation, and one patient To sum up. I am not of the opinion that the who was at first remarkably well, now has con- earlv post-cibal or dumping symptoms are suffi- siderable financial and domestic troubles and ciently frequent or severe enough to cause alarm. relapsed. They can, however, be disturbing in a certain This method can be quite dramatic in its good small group of cases. The severity of the dis- effects. It relieves biliary vomiting and diminishes turbance can be minimized by warning the patient or abolishes diarrhoea. Some patients who were that these attacks are likely to arise for a limited unable to take milk or egg can now take it with space of time. In our own series we found the comfort. It is our only present reasonably satis- attacks less common after the gastro-duodenal and factory solution to the problem. antecolic gastro-jejunal anastomosis, and so we 6. The last method of treatment is by jejunal favour these operations on that account. If the http://pmj.bmj.com/ or colonic replacement of the stomach. We used attacks do develop, it is reasonable to reassure the the jejunal method with considerable doubt and patient, for the severity of the attacks diminishes trepidation in three cases. In two the conversion with time. was carried out for cases of dumping associated Further surgery should on no account take place with a gastro-jejunal stoma. The operation itself less than a year after operation, because o£ -the is delightfully simple. Both cases had immediate tendency of the symptoms to abate. Before a second relief of their symptoms and one remains very operating tiune for post-cibal on September 27, 2021 by guest. well at eight months and has gained eleven pounds .symptoms there is one piece of advice I would in weight. The second began to get severe ulcer give most earnestly, and it is this. Look up the pain within six weeks and gastroscopy four months first notes of the patient-read the letter sent by after operation showed extensive jejunal ulcera- his doctor when he first came. This may be a tion. At re-operation the replacing loop of revelation. There is an all too facile tendency to jejunum was extensively ulcerated, and so it was attribute to a gastrectomy all the ills that subse- removed and a Billroth I form of anastomosis quently befall the patient. In two of my very worst made instead. The patient still remains free of so-called post-gastrectomy dumping cases, I studied his dumping symptoms and this helps to confirm the earliest symptoms and found that the fatigue, my belief that the major benefit of jejunal and and bloating after meals, palpitations and feelings probably of colonic replacement is the re-direction of weakness were all complained of prior- to the of gastric chyme through the duodenum. The gastrectomy-in addition to the ulcer symptoms risk of stomal ulceration is less with colonic and only the ulcer symptoms had been cured by 5z6 ,,.POSTGRADUATE MEDICAL. JQURNAL October I954Postgrad Med J: first published as 10.1136/pgmj.30.348.523 on 1 October 1954. Downloaded from

OPERATIONS FOR 'DUMPING SYMPTOMS Operation No. Results I. Vagotomy ...... 4 -All failed 2. Jejuno-jejunostomy: (a) Alone ...... 2 i cured, I I.S.Q. (b) P'us vag(otomy ...... 2 2 failed (c) Pantaloon operation ...... 2 I cured, i improved 3. Roux conversion (2 plus vagotomy) ...... 3 i well but anaemia, I stomal ulcer, I I.S.Q. 4. Capper suspension ...... 3 All failed 5. Conversion to Billroth I ...... 26 See below. 6. Jejunal transplant after Billroth I ...... I Failed the gastric resection. Needless to say, technical In all these cases the anaemia was microcytic variations in the operation will not relieve such and responded to iron therapy, though it would patients. Furthermore, two of my old gastrec- gradually relapse if iron was discontinued. Mr. tomy patients who developed carcinomas were for Burge made similar careful examination of a group a time returned to us as cases of post-cibal symp- of female cases and found the same trend, though toms. Carcinoma of other organs than the stomach as might be expected, it was more exaggerated, should be considered when old gastrectomy cases e.g., at the end of five years 84 per cent. had a lose weight severely or become suddenly anaemic. haemoglobin below 85 per cent. Of course it is possible for carcinoma to develop We advise our gastrectomized patients to take in the gastric stump, for B. F. Swynnerton and iron-containing foods and warn them of the N. C. Tanner (I953) record that four patients out symptoms of iron deficiency anaemia. In the of 254 developed cancer in the gastric remnant follow-up of 6ii of our gastrectomy patients Protected by copyright. by bletween five and twelve years after gastrectomy Craig and Chippendale, I2 were suffering from, or for simple gastric ulcer. had been treated for a microcytic anaemia, an Now if it is found that the dumping symptoms incidence which was not significantly greater than are truly consequent on the gastric resection, and that among patients without operation. particularly if much biliary vomiting or weight I have seen only one macrocytic anaemia loss is complained of, then further surgery can be following one of our gastrectomies.. This was a considered. The procedure we have found most patient who had had a total gastrectomy, splen- satisfactory is conversion of a gastro jejunal into a ectomv and hemi- for carcinoma. gastro-duodenal anastomosis. If the dumping He was very well and had a blood count within persists after a Billroth I form of anastomosis, then normal limits for six years after operation and then no surgery is advisable unless it can be shown that quite suddenly became anaemic, and the anaemia there is recurrent ulceration, stomal obstruction or was found to be a macrocytic one. a mechanical defect. Weight Loss following Gastrectomy http://pmj.bmj.com/ Anaemia Following Gastrectomy The cases of weight loss following gastrectomy. It is well known that iron deficiency anaemia usually result from diminished intake of food is common in patients with achlorhydria and we rather than any deficiency of fat digestion. (Brain cannot expect to reduce the gastric acidity radically and Stammers (I95i).) Thus the comfortable without getting diminution of the powers of iron patient usually maintains or gains weight, but if absorption. My friend, Mr. Harold Burge of the there is some post-prandial fullness, dumping,

West London Hospital has surveyed large numbers biliary regurgitation, pain or stenosis from stomal on September 27, 2021 by guest. of our cases and his own and finds that there is a ulceration, then intake is restricted and the weight tendency for the blood haemoglobin percentage to may fall., The treatment of weight loss is to treat fall with each year following partial gastrectomy. any of these causative lesions and to encourage He has kindly placed this Table at my disposal. the intake of a high calorie diet. In our afore- mentioned series of 6i i gastrectomies it was found * GASTRECTOMY FOR SIMPLE PEPTIC ULCER that compared with their Male Cases best or normal weight, (50 cases examined in each year) 244 (53 per cent.) had gained weight, i6o (34 per Years after Gastrectomy cent.) had lost up to one stone and 6o (I3 per I 2 34 5 6 cent.) were more than a stone under weight. The .Igb. below: % % % O/

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-II | E i|g1-lwl http://pmj.bmj.com/ on September 27, 2021 by guest. FIG. i8.-The Heineke-Mikulicz py- loroplasty. A-The deformity due to duodenal ulceration, note the diverticula between and the ulcer scar. B-A longitudinal incision through pylorus and scar CI is pulled out transversely. C-The incision is sutured transversely. October I954 TANNER: Surgery of Peptic Ulceration and its Complications 529 Postgrad Med J: first published as 10.1136/pgmj.30.348.523 on 1 October 1954. Downloaded from number than might be expected in an examina- surprise that this simple procedure greatly ex- tion of 515 people in these age groups. The pedited gastric evacuation, even in those without finding is to my mind on a par with that of the the slightest duodenal narrowing. This removed iron deficiency anaemia. In order to cure the most of the trouble. A Finney type of pyloro- ulcer we have lowered the hydrochloric acid con- plasty was necessary in two children whose de- centration in the stomach. We know that in the formity was considered to be too extreme for the presence of hypoacidity, iron and vitamin absorp- Heineke Mikulicz operation. We used gastro- tion may be impaired. It is, therefore, not sur- jejunostomy in a few cases where the duodenum prising that a small percentage of these cases will was extensively damaged, though we avoided it as get iron or Vitamin B deficiency. It is wise, I a routine, because although it may well eventually think, to advise the gastrectomized patient to take prove to be the most satisfactory addition to a slight excess of iron and Vitamin B in the diet, vagotomy, it would have clouded the issue as it in order to compensate for this deficiency. It is is itself curative of the duodenal ulcer. fortunate that the deficiency can be so readily overcome. Technique of Vagotomy The results of vagotomy depend on a scrupulous Vagotomy for Duodenal Ulcer technique. The transthoracic approach is un- I mentioned in my first lecture that vagotomy suitable because the nature of the lesion cannot is still under trial in the treatment of duodenal be confirmed, and the so-called drainage operation, ulceration. In I943 I carried out two or three the pyloroplasty, cannot be added. We use a high partial vagotomies combined with fundusectomy, abdominal approach, sometimes removing the but it did not appear to be verv effective. In 1947 xiphisternum and then reflect the left lobe of the being convinced that complete vagal section had to the right, after dividing the left triangular great potentialities for benefit to the ulcer patient, ligament. The oesophagus is exposed by a trans- Protected by copyright. we felt it our duty to try to assess the operation verse incision through the two distinct layers over as rapidly and as scientifically as possible. In it, the and the phreno-oesophageal order to be sure that anv beneficial effects were in ligament. In order to steady the oesophagus it is fact due to the vagotomy, we decided to use pure usual to put a tractor tape round it. I gave up vagotomy without accessory operations in a fairly this practice because I feared it might increase the unselected series of duodenal ulcer cases. In cases liability to cardiospasm and because it obscures where there was gross duodenal stenosis, correc- the lower vagal branches. Instead I pass a rubber tion of the mechanical defect was imperative and band through the lesser omentum into, and then so we added a Heineke Mikulicz pyloroplasty in through the roof of the lesser sac over the fundus these cases (Fig. i8a, b and c). Our previous of the stomach to the left of the oesophagus experiences of simple pyloroplasty for duodenal (Fig. I9). On drawing this down the branches of ulcer were enough to persuade us that it was not the anterior vagus nerve to the body and lesser a curative operation and that any beneficial results curve of the stomach and to the liver can be easily from the combination could be safely attributed dissected and the branch of the posterior vagus http://pmj.bmj.com/ to the vagotomy. to the coeliac artery can be readily palpated. The Following this programme we soon came into nerves are cuit well down on the stomach after trouble, for although those who needed a pyloro- they have divided into branches, and also as high plasty did well on the whole, some of those who as can be reached through the oesophageal hiatus. simply had a vagotomy suffered greatly from After carefully searching for any accessory vagus gastric retention, foul sulphurous belching and fibres, the opening in the phreno-oesophageal some had diarrhoea. This led to a good deal of ligament is closed to prevent subsequent hiatus on September 27, 2021 by guest. personal discomfort and domestic upset to the herniation. Following this the pyloroplasty is patients, and it is well known that many surgeons carried out. abandoned the vagotomy operation altogether on Like many others we made several early this account. It appeared to us, however, that follows-up which showed reasonably satisfactory this condition which is also seen in cases of results, but the results were confusing because of obstructive oesophageal or gastric cancer, was due the number of recent cases. I really do not think to the combination of hypoacidity with gastric we should draw conclusions on anything less than statis. In a way it revealed the effectivity of a five year follow-up, and that is why, when I am vagotomy. We decided that one of these factors, asked ' What is the place of vagotomy in the obviously the stasis, must be overcome. Con- treatment of duodenal ulcer ? ' I have to answer sequently, in I948 we decided that we must that I do not know. However, the reply to the abandon simple vagotomy, and thereafter we added question is slowly emerging. On the fifth a pyloroplasty in all cases, for we found to our anniversary of their operation, all our vagotomy POSTGRADUATE MEDICAL JOURNAL October 1954Postgrad Med J: first published as 10.1136/pgmj.30.348.523 on 1 October 1954. Downloaded from

m...... Protected by copyright. http://pmj.bmj.com/ FIG. I9.-The author's method of traction over the gastric fundus-which allows good exposure of the branches of the vagus nerve. cases come to the hospital for careful assessment by The causes of the poor results were as follows: Dr. Brian Swynnerton, our Weir Research Assistant. The results to date or prior to any TABLE IA on September 27, 2021 by guest. secondary operation, containing as they do mainly Gastric retention 19 our early pure vagotomy cases, do little more than Active recurrent duodenal ulceration 4 confirm our dissatisfaction with that operation. Ulcer-type pain, scar only at later operation 4 (The Visick classification is used.) Later gastric ulcer Miscellaneous I TABLE I NOTE.-Of the 29 unsatisfactory cases, 27 have had Simple Vagotomy for Duodenal Ulcer subsequent operations (1I3 pyloroplasty, 7 gastro- (No secondary operations) jejunostomy and i i partial gastrectomy). Number of cases ...... 55 Died since (not of ulcer) .. .. 2 Very satisfactory ...... 19 35.8% Minor symptoms not controlled by care The final state of the 53 surviving simple (IIIs) . 5 9.4% vagotomies with their various drainage and re- Unsatisfactory (IIIu) ,,29 54.7% section operations is as follows: October I 954 TANNER: Surgery of Peptic Ulceration and its Complications 531 Postgrad Med J: first published as 10.1136/pgmj.30.348.523 on 1 October 1954. Downloaded from

TABLE 2 Side Effects of Vagotomy Original simple vagotomy cases + 3' further operations What are the untoward effects which lead to on 27 cases. Five year follow-up Very satisfactory (Gdes. I and II) 28 52.8% poor results ? Naturally a small proportion are Minor symptoms not controllable 8i.I due to bad selection-severe functional overlay, by care (IIIs) ...... IS 28.3%J menopausal symptoms, mental disease, associated Troublesome symptoms (IIIu and incapacitating diseases-tuberculosis, bronchitis, IV) * *. . 5 9.4% Too soon since last operation to etc.-these are found in any medical or surgical assess ...... 5 9.4% follow-up. Belching, vomiting and epigastric cramps are Total ...... 53 mainly due to gastric retention and have been largely overcome by the routine addition of a It has been noted by many workers that the ' drainage ' operation. Severe diarrhoea has been final result is much better when vagotomy and the relieved by correction of gastric stasis. However, drainage operation are done primarily than when a certain amount of looseness of the bowel- a drainage operation is done after the vagotomy usually in the early morning may occur, but does has produced severe and prolonged disability from not trouble the patient much and is controllable by stasis. This is confirmed by our own series, in intestinal antiseptics. which four secondary gastro-jejunostomies for Cardiospasm has always been transitory, though post-vagotomy stasis all gave poor five year I did have to remove an inspissated meat results, two as a result of stomal ulceration. bolus from the lower oesophagus of one patient eighteen months and again five years after Vagotomy and Pyloroplasty vagotomy. Hypoglycaemia-like attacks are troublesome in This combination has been our main operation a small percentage of cases but tend to be transi- Protected by copyright. and from its late results we hope to gain a good tory and to improve when gastric stasis is corrected. deal of information on vagotomy. However, I doubt if recurrent gastric ulceration is really only four cases in which both procedures were due to vagotomy. The two cases we have seen done coincidentally have reached the five year may well be small ulcers present at the first mark. Three are very satisfactory and one has operation, which continued to progress despite minor troublesome symptoms. vagotomy (neither had been gastroscoped). I do Vagotomy and Gastro-Jejunostomy not think there is any evidence that vagotomy will Fifteen patients including one operation death. be of any great help in cases of gastric ulceration. Results in the remaining To sum up we can say that simple vagotomy I4: for duodenal ulcer should be abandoned because of TABLE 3 its severe retention symptoms. We can say that Vagotomy and Coincident Gastro-Jejunostomy. Five secondary operations after severe -retention symp- result toms are established improve the situation but

year http://pmj.bmj.com/ Very satisfactory (I and II) ...... II will only completely relieve about half of them. Minor symptoms (IIIs) ...... I The best results will be obtained when vagotomy Troublesome symptoms (IIIu and IV) .. .. 2 and a ' drainage operation' are done at the same One of those with troublesome symptoms had time and on our present small figures, between developed, a stomal ulcer and is now very satisfied 75 per cent. to 85 per cent. prove satisfactory at following a gastrectomy. The other is meno- the end of five years. I do not feel prepared to pausal, but as she attributes all her symptoms to make a personal opinion on the operation until I the operation she must be adjudged a poor result. have studied far more of our cases on the fifth on September 27, 2021 by guest. I have not quoted the results of many other anniversary of their operation. It is too important surgeons because nearly all report a mixture of a matter in which to hazard an opinion, when recent and older cases. However, reports of four patience will reward us with a clearer view of the years and upwards generally show about an 85 per truth. cent. satisfaction rate for vagotomy plus gastro- (The third lecture of this series will be published jejunostomy (Pollard et alii, 1952). in the next number of this journal.)