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SURGICAL TREATMENT of CHRONIC GASTRIC and DUODENAL ULCER by RODNEY MAINGOT, F.R.C.S

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SURGICAL TREATMENT of CHRONIC GASTRIC and DUODENAL ULCER by RODNEY MAINGOT, F.R.C.S '43 Postgrad Med J: first published as 10.1136/pgmj.24.269.143 on 1 March 1948. Downloaded from SURGICAL TREATMENT OF CHRONIC GASTRIC AND DUODENAL ULCER By RODNEY MAINGOT, F.R.C.S. Surgeon, Royal Free Ho;pital; Senior Surgeo?a Svuthend General Hospital Much of the confusion of thought and teaching progressive loss of weight; (i) hour-glass which now exists regarding the surgical manage- stomach; and (ii) pyloric obstruction. ment of patients suffering from chronic gastric and (d) Failure of healing of the ulcer despite pro- chronic duodenal ulcer arises from the fact that in longed (four-eight weeks) and well-supervised in- recent years it has become customary to class these patient medical treatment. two conditions together as one disease-peptic (e) Recurrence of ulceration following (i) one or ulcer. more courses of in-patient medical treatment; (ii) It is true that chronic gastric and chronic simple suture of an acute perforation; (iii) -wedge- duodenal ulcer have certain features in common; or V-excision of the ulcer or other type of un- the early signs and symptoms presented by the suitable operation; or (iv) transgastric transfixion two conditions are in many respects similar, the and obliteration by sutures of the ulcer crater toi Protected by copyright. acid gastric chyme plays an all-important role in control severe haemorrhage. the perpetuation of the lesions, and the medical (f) Multiple chronic gastric ulcers or combined measures advocated for their treatment are almost gastric and duodenal ulcer. identical. (g) The suspicon of malignancy which cannot be Nevertheless, the risk of malignant transforma- excluded by combined clinical, biochemical, tion, the degree of morbidity and the potentialities radiological and gastroscopic examination. of disaster with the accompanying economic dis- (h) The patient is 6o years of age or over, turbances are factors which differ widely according having an ulcerating lesion in the stomach, and to whether they are associated with chronic giving' a short history of dyspepsia. duodenal ulcer or with chronic ulcer of the (i) Ulcers situated on or about the greater curva- stomach. ture of the stomach or in the pyloric region. Cancerous. degeneration of a duodenal ulcer is (j) A large gastric ulcer which has penetrated such a rare event as to constitute a pathological deeply into the substance of the pancreas or liver. http://pmj.bmj.com/ curiosity, but the malignant transformation of a (k) Expedient circumstances and economic gastric ulcer is a potent factor to be reckoned with reasons in certain-instances, e.g., indigent patients, in treatment, and is indeed an ever-present menace mental cases with callous lesions, etc. which cannot be ignored. The surgical treatment of these two diseases also (2) Some Factors Influencing the Choice varies in many important details, and it is for these of Treatment reasons in particular that I propose to discuss them Every patient is subjected to the same routine on September 26, 2021 by guest. separately. clinical methods of investigation, and if the presence of an ulcer in the stomach has been (A) Chronic Gastric Ulcer demonstrated by means of X-rays, and in certain (1) Indications for Operation cases by gastroscopy, the physician and surgeon should meet in consultation and decide the The main indications for operative interference method of treatment to be undertaken. The may be detailed as follows following factors will influence the choice of (a) Acute perforation. treatment (b) Intermittent or continuous haemorrhage (a) Hour-Glass Deformity. This lesion, which arising from the base of a chronic gastric ulcer is due to a stenosing ulcer of the stomach, is ex- which efficient medical qxeasures are incapable of tremely rare in men (about 2 per cent.) and arresting. seldom responds to medical therapy. In the- (c) Anatomical organic deformity of the stomach absence of other contra-indications gastric re- due to stenosing ulceration and associated with section is the best form of treatment. POST GRADUATE MEDICAL JOURNAL March 1948 Postgrad Med J: first published as 10.1136/pgmj.24.269.143 on 1 March 1948. Downloaded from In women it is conceivable that medical treat-I they require surgical attention as soon as they are ment, or rather stringent dietetic measures, may diagnosed. Matthews (I935), who described two maintain a state of nutrition compatible with personal cases and analysed 139, voices the opinion tolerable health if on healing the ulcer has left a held by most surgeons. He writes: small but adequate channel for the passage of food. ' Ulcers of the greater curvature produce no But the majority of such patients are elderly or characteristic symptoms distinguishing them from have suffered from dyspepsia for many years and other peptic ulcers. There is no certain method of have become chronic invalids; sooner or later determining whether a lesion found on the partial gastrectomy (for choice) or gastro-gas- greater curvature ig benign or malignant, except trostomy (when gastric resection is not feasible) by histological examination. A review of the must be performed to overcome the effects of cases described illustrates how difficult it may be obstruction. to differentiate this type of peptic ulcer from I would regard hour-glass deformity associated carcinoma.' with progressive loss of weight and strength as a Simple ulcers of the greater curvature are rare, definite indication for operative interference at any and less than 200 cases have been reported to date. age, and I have successfully performed partial As these 'lesions are easily visualized on gas- gastrectomy (under local anaesthesia) upon patients troscopy and on barium meal X-ray examination, who were aged 71, 75, 78 and 8i respectively, with their response to the therapeutic test can be closely good immediate and late results. observed. (b) The Age of the Patient. With Roscoe In a personal series of six cases of chronic ulcer Graham (1937) and other surgeons,-I have so far of the greater curvature, four were subjected to failed to find a simple chronic gastric ulcer which gastric resection, and the microscopic examination has not been accompanied by clinical Evidence of of the lesions proved that two were innocent and its presence in a patient under 6o years of age. In two were malignant. In the other two cases, asProtected by copyright. other words, I believe that all gastric ulcers which the clinical, radiological and (in one case) gastro- make their appearance after 6o years of age are scopic evidence supported the diagnosis of simple ulcerating carcinomata, and the patient should be ulceration, medical treatment was given a trial advised to have a partial or subtotal gastrectomy which proved to be successful, as the ulcer ap- performed as soon as adequate pre-operative peared to be healed soundly in each case within preparation permits. six weeks. Subsequent examinations of these Patients under the age of 40 who give a relatively cases has shown the healing to be satisfactory. short history of ulcer and who on barium meal Ulcers of the greater curvature should be treated X-ray examination are found to have a 'small on their merits. If the presence of malignancy niche on the vertical portion of the lesser curvature cannot be ruled out after expert investigation, or if are best treated medically. Patients who show a the crater stubbornly refuses to shrink following a satisfactory response to medical therapy should be course of intensive medical treatment, then it is examined at intervals over a period of some years wiser and safer to operate than to wait and see. http://pmj.bmj.com/ to ensure that the healed area in the stomach is In my opinion, the majority of ulcerating lesions staunch. of the greater curvature can. be diagnosed Aged and infirm patients respond poorly to accurately by modern methods, and I consider medical measures, but the risks of operative in- that the incidence of malignancy in circum- terference may be considerable. Each case has to scribed lesions in this 'particular part of the be judged on its own merits, but the bias would, stomach has been exaggerated. I do, however, on the whole, be in favour of medical treatment. believe with Holmes and Hampton (I932) and (c) Sex. The proportion of men to women Finsterer (1934) that gastro-duodenal' resection is on September 26, 2021 by guest. suffering from gastric ulcer is about three to one, the best form of treatment for chronic ulcers of the but gastric resection is called for in approxi- pyloric region, as they are frequently cancerous in mately four times as many men as women. There nature, leisurely or obstinate in their response to is, however, considerable variation in these pro- medical therapy, 'and a cause-though by no portions in different parts of Great Britain and means the commonest-of pyloric obstruction. even in different quarters of any large city. My When this area is the seat of a small destructive experience has been that malignant degeneration lesion visualization through a gastroscope is often of a gastric ulcer is commoner in women than in impossible or fleeting at best; serial X-ray men. pictures of the belladonna- and barium-filled (d) The Position of the Ulcer. It is frequently writhing spastic gastric. outlet usually fail to stated that ulcers situated on or near the greater demonstrate the niche, the meniscus, or the tell- curvature of the stomach or in the pyloric (egion tale filling defect; and the clinical picture, is that are commonly malignant in character, and that of a low-grade or established obstruction with its March i948 MAINGOT: Surgical Treatment of Chronic Gastric and Duodenal Ulcer Postgrad Med J: first published as 10.1136/pgmj.24.269.143 on 1 March 1948.
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