Operations for gastric ulcer: a long-term study.

This study assesses the long-term results of operations for benign gastric ulcers. Three-hundred forty-nine patients operated upon between 1950-1979 have been followed over the past 20 years with a mean and median follow-up of 11.8 and 11.1 years. Fifty-five per cent of the patients had a gastric resection without vagotomy; 19.8 per cent had gastric resection with vagotomy; and 20.3 per cent had vagotomy, pyloroplasty, and wedge excision or biopsy of the ulcer. Operations were selected based on the type of ulcer (Types 1-4), whether the surgeon suspected cancer preoperatively, whether the operations was elective or an emergency, and the age and general health of the patient (presence of significant co-morbid disease). Overall mortality was 6.9 per cent, with a mortality for elective operations 3.6 per cent, and for emergency operations of 32.5 per cent. Age and cardiovascular disease were significant factors in operative mortality and morbidity. All operations were equivalent in long-term results. Excellent to good results were obtained in 92 per cent of patients, with an ulcer recurrence rate of 4 per cent. We conclude that vagotomy, pyloroplasty, and wedge excision or biopsy of a benign gastric ulcer is a comparable operation to a more major gastric resection, with or without vagotomy, in the surgical management of gastric ulcer. The addition of vagotomy to gastric resection does not appear to improve long-term results.

Results of surgical treatment of periampullary tumors: a thirty-five-year experience.

Data on 126 consecutive patients with periampullary tumors resected at the Cleveland Clinic between January 1950 and December 1984 were reviewed. One hundred five patients underwent pancreatoduodenal resection, 10 patients total pancreatectomy, and 11 patients local resection of the tumor. The site of tumor was ampulla of Vater (59), head of the pancreas (30), duodenum (20), and distal common bile duct (11). Six patients had benign disease. The operative mortality rate for radical resection for the entire period was 7.8%; it has declined to 5.4% since 1974. The operative mortality rate for local resection was 9.1% (one patient). The overall 5-year survival rate for all malignant tumors of the periampullary area was 28% and 25.5% for invasive adenocarcinoma. Survival was affected primarily by location and histologic findings. The 5-year survival rate for adenocarcinoma of the ampulla of Vater was 37.2%, 27.5% for the duodenum, 16.7% for the distal common bile, and 4.3% for the pancreas (p = 0.0001). Papillary adenocarcinoma had a 5-year survival rate of 49.2% in contrast to 18.4% for nonpapillary ductal adenocarcinoma (p = 0.002). Patients with ampullary adenocarcinoma treated by local resection had a 5-year survival rate of 40.9%. These data justify continued use of a selective radical approach in the resection of most periampullary tumors with local resection for small tumors in high-risk patients.

Results of conservative operations for breast cancer.

The results of conservative operations for breast cancer in 1,593 patients treated at the Cleveland Clinic between 1957 through 1975 are reported. During this period, we individualized our treatment of breast cancer depending on tumor size, location in the breast, and clinical stage of the disease. The following three principal operations were performed: modified radical mastectomy in 592 patients (37%), simple (total) mastectomy in 442 patients (28%), and partial (segmental) mastectomy in 291 patients (18%). Survival results at 5, 10, and 15 years are reported. Factors important in long-term survival included stage of the disease, number of lymph node metastases, delay in therapy, size of the tumor, histologic type, and estrogen receptor status; type of operation was not a significant factor. In this series, partial (segmental) mastectomy without radiation therapy provided five- to 15-year survival rates equal to modified radical mastectomy and simple (total) mastectomy.

Gastric carcinoma. A ten-year review.

Data on 164 patients treated at the Cleveland Clinic with gastric adenocarcinoma during the ten year period 1970 to 1980 was analyzed. Fiberoptic esophagogastroduodenoscopy was introduced as a routine diagnostic modality during this time and yielded a positive tissue diagnosis in 86% of patients in this series. Laparotomy was performed on 150 patients; 49 patients (30%) were biopsied only, 19 (12%) were bypassed for palliation, and 82 (58%) underwent gastrectomy. Of the latter group, only 45 patients (27%) were resected for cure. The overall operative mortality rate was 6%. All patients were staged according to the International TNM classification (stage I--10%, II--24%, III--12%, and IV--53%). Survival at 5 years was influenced by tumor location and extent of gastric resection but was most significantly related to stage of disease at operation (stage I--65%, II--22%, III--5%, and IV--0%; p less than 0.0001) and to the status of regional nodes (positive--17%, negative--56%; p less than 0.005). Despite the routine use of fiberoptic endoscopy, the majority of gastric cancers were advanced at diagnosis and their prognosis remains discouraging. Improvement of results will require a more aggressive approach to the endoscopic investigation of upper gastrointestinal symptoms and earlier surgical intervention.

Long term results in patients who survived five or more years after gastric resection for primary carcinoma.

A personal series of 82 patients with primary carcinoma of the stomach operated upon between 1 January 1950 and 31 December 1973 survived five years, of longer, after the initial resection. Fifty-five patients were observed until the time they died, and 27 patients who are still alive have been observed from eight to 29 years. Many of the patients have lived into their 80's and 90's, with postoperative survival times of more than 20 years. Some of the long survival times followed both extensive operative procedures upon unfavorable lesions and operations upon patients who were in their 70's at the time of operation. A surprise finding as the cause of death was a recurrence of carcinoma in 13 patients, manifesting itself as long as 12 years after the initial operation. In six of the patients, the recurrence was confirmed at a second operation performed by me. The long term results in these patients seem to indicate that, except for the late recurrence of carcinoma, at least one-third of the patients may look forward to a normal life expectancy based upon their age at operation. The surgeon, therefore, should approach potentially curable carcinoma of the stomach with vigor and some optimism, even though the lesion is extensive or the patients are elderly, since a long healthy period of survival may be the reward.

An interpretive review of lymphoma of the stomach.

Lymphoma of the stomach may exist as a primary lesion or as a manifestation of generalized or systemic lymphoma. The primary lesions constitute approximately 3 per cent of all malignant lesions of the stomach and outnumber all other types of non-epithelial malignant lesions. The cause is not known. Gross characteristics often resemble carcinoma, and like carcinoma, the primary lesion may affect other structures by direct extension, may seed to peritoneal surfaces, may metastasize to lymph nodes near or far, and may be borne by the blood to liver, lung or bone. Diagnosis begins with clinical suspicion by the physician, is supported by the results of roentogenographic and gastroscopic studies, and is finally established by a positive study of biopsy specimens obtained with or without laparotomy. Improvements in both gastroscopic instruments and their use promise to increase greatly the accuracy of preoperative diagnosis. Pseudolymphoma of the stomach, a rare type of inflammatory lesion, may, on occasion, offer a difficult differential diagnosis from that of lymphoma. The clinical approach to the lesion, whether the diagnosis is histologically proved or not, is the same as for suspected carcinoma. A laparotomy is usually necessary to determine the possibility of surgical cure, unless distant spread or systemic involvement can be established by other means, such as a distant lymph node containing the disease or a positive needle biopsy of the liver. When a cure seems possible, resection is favored by most surgeons, even though it entails total gastrectomy or multiple organ resection. Opinion is divided as to whether or not a curative resection should be followed routinely by irradiation, although irradiation is generally favored by palliation of lesions not amenable to resection. Transgastroscopic biopsy and gastroscopic follow-up study may permit radiation to be tested as the only form of treatment of favorable lesions. At the present time, chemotherapy should be reserved for lesions not controlled by operation or irradiation. Stage for stage, the outlook for lymphoma of the stomach is about twice as favorable as that for carcinoma. No generally accepted classification of lymphoma exists as yet. Correlations between prognosis and microscopic characteristics are not close, except for the generally favorable outlook for lymphocytic lymphoma.