On Present tou Surgery of Stomach and Duodenum with Special Reference to Therapy in Acute Complications of Ulcerous Diseases

Abstract

Our brief examination of the aetiology and pathogenesis of ulcerous diseases has resulted in the conclusion that, since a number of relevant points remain obscure- no satisfactory answer has yet been found to the problem. Hence it is that ulcers are still being treated symptomatically — never causally.

As regards the acute ulcerous complications the case is rather different, i.e.  a surgical intervention is indicated here as a matter of vital importance.

In the treatment of ulcer perforations, both covered (perforatio. tecta) and open, our Clinic gives the primary resection the preference over other operative and conservative methods — provided the patient’s general condition allows it. In weighing the pros and cons our first consideration is the cardio- vascular system of the patient; the local condition, duration and age come next in importance.

The urgency of surgical intervention in the "perforatio tecta" is justified by the occurrence of various complications that ariše in the event of delayed intervention; in order to prevent these and aid the recovery, an early operation offers a better chance than does any conservative therapy.

The preference given to the primary resection of the stomach over other operative and conservative methods of treatment is based on the following facts:

(i) The mortality rate is not any higher than in cold ulcer resection;

(ii) The technique of resecting is much simpler than after the sutures have been made or the draining done in consequence of the perforation;

(iii) The primary resection does away with the ulcer which has a tendency to undergo perforation again, and in addition to give rise to haemorrhage ox- malignant tumours consequent on degeneration;

(iiii) The primax-y resection removes not only the ulcer but a whole series of factors that are responsible for the rise and growth of ulcerous disease;

(iiiii) Most patients who have been subjected to opcration for simple sutures show great reluctance to undergo further treatment or operation — unless compelled to do so at the last moment owing to reperforation or bleeding.

However, if the general condition or the age of the patient is such as to preclude the primary resection, then a simple sutural closure of an acute perforation is to be carried out.

In big callose perforated ulcers where for various reasons the resection is impracticable and the right suturing difficult to do or likely to result in the stenosis of duodenal lumen — in such cases the draining is performed in accordance with the Neumann-Haberei procedure.

In exceptionally severe cases whcre a surgical intervention is not to be thought of we have recourse to continucd suction, intra-arterial blood transfusions, cardiacs and antibiotics — as a last resource.

In the case of bleeding ulcers our climcians give the operative treatment the preference over the conservative therapy. The reasons for this are many points the modern pathophysiology has succecded in elucidating and which in latent and recurrent haemorrhages due to hypoxie are responsible for the impairment of myocardium, parenchymatous organs and vital subcortical centres.

With reference to the primary mass haemorrhage it is of the first importance, according to the authors, that the checking of a haemorrhagic collapse (by blood transfusions) and the balancing cf metabolism should be followed up by instant surgical intervention, i.e. the resection performed and the bleed­ ing ulcer removed if the general condition of the patient allows it, otherwise the eroded blood vessel need only be tied down. The surgical intervention is conditional on an adequate supply of conserved blood.

Yet if the patient has been scveral hours or days late in reporting the illness, he should be kept under observation and the operation delayed until he is fit enough to undergo the operative trauma with safety.

Latent and recurrent bleeding calls for immediate surgical intervention; but it will brook no delay, or else the time will have gone when the surgeon’s assistance is most effective.