Gastrojejunal ulceration

Abstract

OUR experience of the nature and frequency of gastrojejunal ulceration is of necessity short, for the first gastro-enterostomy was performed by Wolfler, at the suggestion of his assistant Nicoladoni, as recently as the year 1881. Possibly because the earlier operations were generally performed for carcinoma of the pylorus, the first case of gastrojejunal ulcer was not reported by Braung until 1899, this being one in which a fatal perforation took place. In the short period of thirty-five years that has ensued since this date our knowledge has been steadily increasing. At first only single cases were reported at long intervals, the first in France being reported by QuCnu in 1902, and the first in this countiy by Mayo Robson in 1904. After this they were found in rapidly increasing numbers, Pater~on,"~ in his epic paper in 1909, first directing widespread attention to the subject, although he found that BrodnitzlS in 1903 was able to collect 15 cases, GossettI7 in 1906 31 cases, and Einer Kay13 a year later added 6 examples. Paterson in his own paper collected 52 certain and I I doubtful cases, 2 of which were from his own practice.Of later years so many examples have been reported that it is no longer practical to collect individual cases but only to consider general statistics. So many indeed have been reported that a keen controversy has arisen as to the actual frequency of the condition. On the one hand, LewisohnZs in 1925 published a series of 68 cases of gastro-enterostomy where 23, or 34 per cent, developed gastrojejunal ulceration after having been watched for a period of not less than five years. Hurst and StewartZ4 believe that it is a dangerous and frequent sequel of gastro-enterostomy. They cast doubt upon the accuracy of many of the figures reported by various surgeons, and claim that the number of anastomotic ulcers slowly but steadily multiplies as the cases of gastro-enterostomy are watched over increasing periods. They give pathological statistics showing a 7.3 per cent incidence in 42 cases examined at Leeds, ten days to two months after operation, and a 52 per cent incidence in 42 cases examined nine months to nineteen years after operation.These, however, must be considered as very selected cases, for the examinations were carried out on patients who had died, and therefore took no cognisance of those who had recovered and might have formed a high percentage of the total operated upon. These extreme views as to the frequency of this dangerous complication are held by a considerable number of surgeons of wide experience. This is especially so on the European continent, where many have abandoned the routine use of gastro-enterostomy and have replaced it by some form of partial gastrectomy. Among those who hold these views may be quoted Finsterer,14 von Habere1-,4~ Hohlbaum,22 von Ei~elsberg:~ and in this country Pannett.38On the other hand, many surgeons, and especially those in this country and the United States, have found that recurring ulceration of this type, although VOL. XXI1.-NO. 85 SURGEO...

Partial Gastrectomy and Peptic Ulcer

“…From then onwards he personally interviewed his old patients at a regular weekly clinic, at which it was later my privilege to assist. In 1934 he reported a 3.2% incidence of gastrojejunal ulcer in a large series of cases (Walton, 1934). This figure was the number of cases recognized by x-ray examination or by surgical exploration.…”

Recurrent Ulceration Following Gastric Resection — A Gastrophotographic and Roentgenographic Study

“…The rarest type of recurrent ulceration is suture-line ulcer, which usually occurs in subjects having very low acid outputs (19). It may follow any kind of gastric surgery in which nonabsorbable suture material is used in some layer of the gastric wall (10,19,22,26). The incidence after gastric resection is reported to be as low as 0.27N, but suture-line ulcers are increasingly recognized with the more widespread use of endoscopic techniques.…”

“…Other reports indicate that ulcers are most often fotmd in the line of the anastomosis (5, 23). One author has concluded that the recurrent ulcers always begin at the anastomotic line, because scarred tissue extending from the stoma to the ulcer was found in all instances (26). Histological study of 87 anastomotic ulcers revealed that the ulcer lay on the jejuna' side in 81, on the gastric side in 3 and on the anastomotic line in 3 cases (24).…”

The surgical treatment of anastomotic ulcer an analysis of thirty-eight cases

“…A similar view was put forward by Balfour (1926), which he later modified. In recent years, however, an increasing number of surgeons have been advocating the use of partial gastrectomy in the treatment of anastomotic ulcer (Lewisjohn, 1930 ;Walton, 1934-5 ;Ginzburg and Mage, 1938 ;Finsterer, 1939 ;Fallis and Warren, 1946), and this is the operation which has been employed in nearly all of the present series; the main advantage of partial gastrectomy being that, up to the present, it is the only reliable way of permanently depressing the acid gastric secretion. Other methods have been introduced in recent years ; the extensive resection of the acid-secreting part of the stomach (Connell, 1934(Connell, , 1939Seely and Zollinger, 1935 ;Zollinger, 1940) ; and the resection of the vagi (Dragstedt and Schafer, 1945 ;Dragstedt and others, 1947; Thompson and James, 1947; Grimson and others, 1947) j but it is too early yet to assess their value.…”