Gastroduodenal ulcer. Overview of 150 papers presented before the Southern Surgical Association 1888-1986.

By the early part of this century, members of the Southern Surgical Association as well as others began to realize that gastroenterostomy alone was unacceptable for the treatment of gastric ulcer. Ulcer excision and some type of limited resection was advised. At a later date, gastric resection of varying extent, depending on ulcer size and location, became the appropriate treatment for complications of this disease. For treatment of complications of duodenal ulcer, gastroenterostomy was widely used from the latter part of the 19th century until the late 1930s. Adequate gastric resection slowly but cautiously replaced gastroenterostomy during the 1940s. Vagotomy with drainage and vagotomy with antrectomy slowly developed and replaced adequate resection by the early 1970s. Beginning in the 1970s and extending into the 1980s, fewer duodenal ulcers were seen, and many of those encountered were being adequately managed using the H2 receptor blockers. For the intractable duodenal ulcer there is currently an increasing trend to use the less invasive operation of parietal cell vagotomy. Vagotomy with antrectomy for such cases is being used less frequently. Vagotomy and drainage has lost much of its appeal. Lesser procedures have been advocated recently for treatment of marginal ulcer after incomplete vagotomy irrespective of the original operation for ulcer. Massive bleeding and acute perforation are still frequently encountered as complications but are being seen more frequently in elderly high-risk patients, some of whom will tolerate only a lesser procedure as suture ligation, vagotomy with drainage, or simple ulcer closure. It appears that we are now seeing a different duodenal ulcer pattern in the good-risk patient. The ulcers are usually small, less virulent, and less likely to be found penetrating into the pancreas and adjacent organ structures. As Claude Welch so aptly stated recently before the Association, "We are seeing a trend in ulcer surgery that is currently being seen in other areas of surgical endeavors as well." He emphasized that we must be alert to changing disease patterns and adapt our procedures to new requirements.

Proximal gastric vagotomy. Follow-up of 109 patients for 6-13 years.

From January 1973 through December 1979, 131 patients underwent proximal gastric vagotomy (PGV) for duodenal ulcer. There were 78 men and 53 women, whose age ranged from 19 to 73 years, with a mean age of 45 years. One hospital death occurred as a result of pulmonary embolism (0.7% mortality). There were 12 late deaths unrelated to ulcer disease, and each of the 12 patients was graded Visick I or II prior to death. Nine patients were lost to follow-up. This report is an analysis of the remaining 109 patients followed from 6 to 13 years. One hundred two patients (93.5%) underwent PGV for intractability. Seven patients (6.5%) who underwent PGV in selective circumstances for either acute perforation (3 patients), bleeding (1 patient), and moderate outlet obstruction (3 patients) are included. Follow-up results reveal that 52 patients (47%) are graded Visick I, 40 patients (36%) Visick II, five patients (5%) Visick III, and 12 patients (12%) Visick IV. Mild diarrhea occurred in 2.8% and mild dumping in 1.9%, and no reflux gastritis or esophagitis was noted. Recurrent ulceration took place in 10 patients, and seven subsequently required reoperation. Two additional patients had the antral pump mechanism denervated and later required antrectomy. PGV has yielded satisfactory results over a 6-13 year follow-up when operation was done for intractability. The low incidence of unpleasant long-term side effects is an appealing feature of the operation. A recurrent ulcer rate of 9.2% (10 patients) has, however, been of major concern. Those with a prime interest in gastric surgery are urged to continue the use of PGV in cases of intractability. Another 10 years of clinical investigative work will no doubt be necessary to determine the ultimate rate of recurrent ulceration.

Experience with vagotomy--antrectomy and Roux-en-Y gastrojejunostomy in surgical treatment of duodenal, gastric, and stomal ulcers.

Gastroduodenostomy (Billroth I) is our reconstruction of choice following gastric resection for gastroduodenal ulcer. Dissatisfaction with a Billroth II anastomosis has led us in recent years to employ a Roux-en-Y diversion in selected cases, particularly those in which the pathologic state of the pyloroduodenal canal would render a Billroth I anastomosis unsafe. During the past 7 years, truncal vagotomy-antrectomy and Roux-en-Y (VARY) has been carried out in 50 selected patients: duodenal ulcer (DU) 13 patients, gastric ulcer (GU) 11 patients, and stomal ulcer (SU) 26 patients. Fourteen patients (28%) developed postoperative complications, of which nine (18%) were of major degree and five (10%) of a lesser degree. No hospital death occurred among the 50 patients. Five patients (10%) developed postoperative delayed gastric emptying and two of the five required revision of the Roux. Forty-five patients had no clinical problems with delayed emptying. Overall results showed a Visick grading of I in 72%, Visick II in 24%, and Visick III in 4%. Further analysis revealed that of the 13 patients with DU who had VARY, 62% were Visick I, 30% Visick II, and 8% Visick III. The 11 GU patients with VARY were graded Visick I 73% and Visick II 27%. Of 26 patients with SU who underwent VARY, 77% were Visick I, 19% Visick II, and 4% Visick III. Mild to moderate dumping took place in 8% of the 50 patients, mild diarrhea 10%, weight loss 10%, and no patient experienced alkaline reflux gastritis. Long-range postoperative gastric emptying studies among nine patients using a radionuclide revealed varying patterns of emptying. Overall clinical results have been satisfactory and we are continuing to use VARY in selected cases, particularly those in which a Billroth I reconstruction appears contraindicated.

Cefoxitin versus erythromycin, neomycin, and cefazolin in colorectal operations. Importance of the duration of the surgical procedure.

Perioperative parenteral cefoxitin was compared with oral erythromycin, neomycin and parenteral cefazolin in a prospective, double-blind, randomized evaluation of 119 patients undergoing colorectal operations. Patients receiving cefoxitin had a higher wound infection rate than patients receiving erythromycin-neomycin-cefazolin (12.5% v 3.2%, respectively, p = .06). A direct correlation existed between the duration of the operation and the infection rate. Cefoxitin prophylaxis was as effective as erythromycin-neomycin-cefazolin in patients undergoing surgical procedures of 4 hours or less (infection rates of 4.8% and 4.0%, respectively). However, for surgical procedures lasting more than 4 hours, 5 of 14 patients (37.5%) receiving cefoxitin developed a wound infection v 0 of 13 patients receiving erythromycin-neomycin-cefazolin (p less than .05). It is speculative as to whether frequent two-gram doses of cefoxitin given during the operation would provide prophylaxis equivalent to erythromycin-neomycin-cefazolin.

Gastric ulceration after fundic wrapping. Vagal nerve entrapment, a possible causative factor.

Transabdominal fundoplication is an effective operation for control of gastroesophageal reflux in the majority of patients. The operation is, however, associated with several sell-documented early and late complications. Recently, a few reports have appeared describing benign gastric ulceration (GU) occurring from one month to several years postplication. The etiology of GU in this setting is unknown, but preexisting delayed gastric emptying, pyloric incompetence, faulty wrap construction, local ischemia, and trauma to the vagus nerves have been incriminated. During a recent seven-year period, five cases of GU have occurred among a series of 158 patients who underwent fundoplication. The cases are cited in detail, and the recent literature is reviewed. Discussion is addressed to the various proposed factors and combination of factors thought to contribute to GU. Suggestions are included for the preoperative evaluation of patients with gastroesophageal reflux as an aid to intraoperative management. As trauma to the vagus nerves has been frequently mentioned as a contributing factor to postplication ulcer, an operative technique is described in which the vagus nerves are isolated and protected from the fundic wrap.

Unusual fungal infections following jejunoileal bypass surgery.

Deep-seated fungal infections with unusual clinical courses developed in three previously healthy patients following jejunoleal bypass surgery. Pulmonary blastomycosis disseminated and then relapsed despite repeated courses of amphotericin B in a 40-year-old man; chronic progressive pulmonary histoplasmosis developed in a 38-year-old nonsmoking man; and histoplasmosis of mediastinal nodes became symptomatic in a 32-year-old man. Cell-mediated immunity was evaluated in two patients; no defects were found. However, male patients were found to be at a significantly higher risk of infection than female patients (3/32 vs 0/101; P less than .02). A significantly higher percentage of prebypass weight was lost by the infected men than the uninfected men (P less than .05). Accelerated weight loss clearly preceded the onset of the infection in two of the patients. Jejunoileal bypass surgery should be regarded as a risk factor for serious fungal infection, especially in men with accelerated weight loss.

Remedial operation for alkaline reflux gastritis and associated postgastrectomy syndromes.

Alkaline reflux gastritis is being recognized with increasing frequency after operations that ablate the pylorus as a true sphincter. Medical management is generally ineffective for patients with severe reflux gastritis, but Roux-en-Y diversion of bile and of pancreatic and intestinal secretions provides gratifying results. We studied 100 patients who underwent remedial operation. Roux-en-Y gastrojejunostomy or Tanner's vs Roux-19 procedure gave good to excellent results in most of the 73 patients followed up for from one to six years. Reflux gastritis can occur in association with other postgastrectomy disorders. Fifteen patients with reflux gastritis also had severe dumping or postvagotomy diarrhea. Good to excellent results were obtained in most of these patients by Roux-en-Y diversion combined with an antiperistaltic jejunal segment.

Regional enteritis with major gastrointestinal hemorrhage as the initial manifestation.

Four patients with massive gastrointestinal hemorrhage were found to have Crohn's ileitis. This prompted a five-year chart review of consecutive admissions for Crohn's enteritis; 60 patients were found whose disease was limited to the distal part of the ileum (and rarely the proximal part of the cecum). Eight (13%) of these patients were admitted because of major rectal bleeding, and in seven of the eight the hemorrhage was the initial manifestation of Crohn's disease. The mean age of the entire group was 30 years, with a mean age of 18.6 years in the eight bleeders. Crohn's ileitis should be considered in the differential diagnosis of massive rectal bleeding, especially in younger patients.

Incidental splenectomy associated with Nissen fundoplication.

Despite the relative frequency of iatrogenic splenectomy, its effect on postoperative morbidity and mortality remains controversial. This retrospective study compares the postoperative morbidity and mortality among 72 patients who underwent a Nissen fundoplication for esophageal reflux and 25 patients who had iatrogenic splenectomy and Nissen fundoplication. The age range in both groups was comparable. In the Nissen fundoplication (N.F.) group the average postoperative hospital stay was 9.4 days and in the Nissen fundoplication and splenectomy (N.F. + S.) group postoperative hospital stay was 15 days. In the N.F. group nine patients (12.5%) experienced significant postoperative morbidity in comparison to 36% in the N.F. + S. group (statistically significant p less than 0.1%). In the later group the complications were of a more severe nature. No mortality occurred in the N.F. group and one patient died in the N.F. + S. group. Iatrogenic splenectomy in this patient could well have been a prime factor in precipitating his demise. This retrospective study stongly supports the view that iatrogenic splenectomy in association with Nissen fundoplication adds considerably to postoperative morbidity.