Problemi ulkusne bolesti (sa hirurškog satanovišta)

Abstract

In the course of this century our knowledge of the origine and! development of gastric and duodenal ulcers has increased considerably. Anatomical and clinical studies as well as a large num­ per of experiments have helped to throw more light on many unclear points in the origin of this disease, but the etiologic problem of the disease is as yet not completely solved. Instead of a clear etiology, we only have certain principal theories (nervous, chemical, gastric and vascular) none of which have been completely disputed up to now. The elements of all these theories have served as the foundation of the modern conception of the gastric and duodenal ulcer disease, which is that it is the product of numerous external and internal factors and conditions. According to modern conceptions the actual ulcer is but a prominent symptom (anatomically) of the disease as a whole, and whose primary causes must be sought outside the stomach in the higher centers of the neuro­vegetative system (hypothalamus) which are in connection with the psychic sphere, and by means of the vagus and sympathicus nerves in connection with the upper digestive tract.

As far as the operative treatment of the ulcer is concerned, there is still no full agreement among the surgeons themselves. The question of operative indications and. of the choice of surgical methods to he employed is still on the agenda. With the advent of new method is of treatment the choice has become even more difficult. This is especially the case in cases of perforation and serious hemorrhage where the attitude of the surgeon is still not clearly defined.

The general impression is, that since the first world war the occurrence of gastric and duodenal ulcers has been much more frequent, and this is probably true although hard to prove statistically. However, what has been undoubtedly proved is that there has been a definite change in the numeric relation between gastric and duodenal ulcers. Whereas before the last two wars the relation stood as 1 to 3, today there are seven times more duodenal than gastric ulcers, if not more. The reasons of the increased frequency of ulcers are no doubt various mental shocks, over great responsibility fear, worry etc., as well as poor and insufficient nutrition, in short all the physical and mental strain to which people were subjected during the war.

All competent authors agree that the acido­peptic effect of the gastric secretion occupied a prominent place, as an immediate cause, in the origin and development of the ulcer. The aim of surgical treatment is to reduce the production of gastric acid and to create as favorable conditions as possible for the unhindered evacuation of the stomach. Radical resection of the stomach, which is still the most efficient method of treatment, accomplishes this at the cost of partially sacrificing the anatomical and physiological whole of the organ.

In the case of serious hemorrhage from the ulcer, the surgeons are still unable to agree completely on the best form of treatment. Most authors, with whom we agree according to our own experiences, consider that it is not advisable to operate immediately after the first large hemorrhage, but to try with conservative treatment. One must of course except cases where it is impossible to maintain blood pressure with blood transfusions (sometimes by means of the intra­arterial method), and also cases which hemorrhage again after a short period of improvement. Here we have to decide on rapid intervention, if possible within the first 24 to 48 hours, as after this term the rate of mortality rises rapidly especially in the case of older persons.

Another, even more serious complication is the perforation of the ulcer into the abdominal cavity. In the course of the last ten years we had 115 cases of perforated ulcers at our clinic which for some time was also an emergency station, and during the same period of time 664 cases of ulcers were operated on and observed. Immediately after the war, in most of the cases we merely sowed up the place of perforation. Lately, however, thanks to the antibiotics, we have been able to reduce the rate of mortality from 16% to 100%, although we performed gastric resection whenever possible.
The conservative treatment of cases of perforated ulcers by means of permanent suction of the stomach contents according to the Taylor method, has not been widely applied in practice. The aim of this method is to avoid immediate operation in cases of shock, especially with elder persons with fairly frequent complications from the cardiovascular and respiratory system, thus creating favorable conditions for operation at some future date, when resection of the stomach can be carried out. This method has both its good and bad sides. A mistake in diagnosis may prove to be fatal, as for instance, if suction is applied in the case of a perforated appendix of gall bladder, if the patient is not seen immediately by the doctor, prolonged suction is out of the question, and in recent cases simple suture of the ulcer or, what is even better, gastric resection gives good results. Apart from this, with this method of treatment one must be most careful not to lose valuable time and the right moment for successfully operating. It may for instance happen that the general improvement in the patient's condition and the local status, which lead us on to continue suction, are only apparently extant and that the sudden turn for the worse which indicates that the perforated ulcer has not obliterated, only occurs after 12 hours or more.

In cases of gastric carcinoma radical resection has been universally accepted, however in the case of a gastric or duodenal ulcer i. e. a disease which is not or very rarely fatal, many surgical methods have been tried out in order to obtain the best and most lasting results at the least risk.

The method of vagotomy in the operative treatment of ulcers, a method based on sound physiological principles, was at first favorably accepted. Later, however, when this method became more widely applied, there were an increasing number of reports that immediate and serious complications had occurred in the form of atony and resultant retention of the stomach contents, as well as vomiting and diarrhea. However, what is even more serious is the fact that in about 25% of the cases treated in this way, the gastric acidity and tonus rose to their former level in the course of the two years following the operation. The same applied to the old pa­ ins, usually in connection with a relapse of the ulcer, the percentage of which rose in proportion to the length of the period of observation. For these reasons vagotomy was no longer applied except in certain rare cases, as an independent operation. Vagotomy is successfully applied in cases of duodenal ulcer with hypersecretion and hyperacidity of a nervous origin, but only combined whit gastro­entero­stomy, or even better with partial resection of the stomach. The application of vagotomy is most justified in cases of postoperative anastomotic relapses of the ulcer after gastric resection, as in these cases renewed resection would be technically much more difficult as well as most dangerous for the patient.

Postoperative relapse at the point of the anastomosis, or more often on the jejunum, is the great draw back of the surgical treatment of ulcers, it occurs most frequently after gastro­entero-stomy, but also in some cases after radical resection of the stomach (Billroth II). The peptic ulcer of the jejunum after gastro­entero­stomy occurs in a percentage varying from 3 to 10, and after re­section from 1 to 2. Our experiences are founded on 56 cases of observed and operated peptic ulcer of the jejunum, seven of which with a gastro­jejuno­colic fistula. The first 35 cases have been reported in the D. med. W., 1939. As to the treatment of the peptic ulcer of jejunum one might briefly sum up the situation by saying that less radical surgical methods, such as excision of the ulcer with reconstruction of the stoma or degastro­entero­stomy with the establishment of normal relations, have not led to lasting results. In most of the cases there were relapses on the sight of the anastomosis or on the duodenum. By far better results were obtained when resection of the anatomized segment was performed together with an extensive resection of the stomach.

Resection en bloc, performed in the case of gastro­jejuno­colic fistula showed a high mortality rate (30 to 60%) due to the poor condition of patients suffering from this affliction. The problem was solved by performing this extensive operation in two stages: first diverting the contents of the large intestine away from the fistula, and later when the vomiting and diarrhea has ceases, performing the radical operation. In this way we were able to re­ duce the operative mortality to 10%.

The large majority of patients suffering from duodenal and gastric ulcers belong to the domain of the physician. About one fifth of the patients can be considered for surgical treatment. They are usually cases with a callous perforating ulcer and persist and pain which does not respond to internal treatment. Further we have the cases of gastric ulcers with a Haudeck's niche which likewise do not respond to internal treatment. Operative treatment is further indicated in cases which are sclerotic and combine with pyloric or mediogastric stenosis. Naturally operation is vital in the case of complications such as frequent hemorrhaging, perforation and neoplastic degeneration.

In the course of the last 20 years we have systematically performed extensive resection (2/3) of the stomach together with the pylorus and the first portion of the duodenum in the case of ulcers. Usually we used the Billroth II method or one of its modifications. The mortality rate at our clinic does not exceed 30;0 except in the cases of serious hemorrhage or perforation of the ulcer. In 90% of the cases we obtained good and lasting results, and this was proved by the lengthy observation of cases after operation. All other conservative surgical methods have been long abandoned! be­ cause of the comparatively large number. of relapses. We perform gastroenterostomy in some very rare cases when the patients are old and with little resistance and have callous ulcers and stenosis of the pylorus without a higher degree of acidity.

Resection of the stomach after Pean ­ Billroth was rarely performed, only in some 70 cases, i. e. a little over 50;0 of the total number of resections for ulcers. Considering the favorable and la­ sting results obtained. I think this method should be more widely applied in spite of the limited possibilities, for it suits the physio­ logical conditions better and is less of a strain for the patient. In this method no postoperative dumping syndrome occurs and there is no possibility of a relapse of the sight of the anastomosis.

Considering the immediate and later favorable results and good health conditions obtained by no other method of treatment, radical resection of the stomach is the method of choice in the surgical treatment of the ulcer, a sort of standard according to which the value of other methods can be judged. Although resection is not an ideal method for treating gastric and duodenal ulcers due to the fact that it encroaches on the anatomical and functional entity of the organ, it is nevertheless the most efficient method and the best means of preventing a relapse of the ulcer.