Posterior Gastro-Enterostomy in the Treatment of Peptic Ulceration

Citation preview

POSTERIOR

GA STRO- EN TERO STQMY

OP THE

PEPTI0 LONG

IN

THE

TREATMENT

ULCERATION. TERM

RESULTS.

T h esis en tered f o r the degree of Ch.M. G l a s g o w U n i v e r s i t y .

DOUGLAS

H.

September,

1949.

CLARK, M . B . , C h . B . , F . R . F . P . S . ( G ) , F . R . C . S . ( E d ) .

ProQuest Number: 13870149

All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is d e p e n d e n t upon the quality of the copy subm itted. In the unlikely e v e n t that the a u thor did not send a c o m p le te m anuscript and there are missing pages, these will be noted. Also, if m aterial had to be rem oved, a n o te will ind ica te the deletion.

uest ProQuest 13870149 Published by ProQuest LLC(2019). C opyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States C o d e M icroform Edition © ProQuest LLC. ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 4 8 1 0 6 - 1346

INJDBX. Page N o. Introdu ction.

1

PART I . 1.

H isto rica l.

4

2.

C r i t i c a l o b s e r v a t i o n s on tHe l i t e r a t u r e .

8

PART I I . P a r tic u la r s of survey. 1. C lin ic a l m aterial.

12

2 . O p e r a t i o n and p o s t - o p e r a t i v e c a r e .

12

3. F ollow -u p .

13

4. A ssessm ent o f r e s u l t s .

17

5. Grades o f s e v e r i t y .

18

6. F a i lu r e curve.

18

7. R e s u l t s .

20

8. O perative m o r t a lit y .

24

PART I I I . A. - A n a l y s i s o f u n s a t i s f a c t o r y r e s u l t s . 1. P a th o lo g y .

27

2 . Symptoms.

29

3 . I n c id e n c e o f major c o m p li c a t i o n s .

30

IRJDEX. Page N o . PART I I I . ( c o n t d ) B - F actors in flu en cin g

resu lts.

1.

S ite of u lcer.

33

2.

Sex.

37 40

3 . Age a t o p e r a t i o n . 4 . D uration of p r e - o p e r a t iv e u l c e r h i s t o r y .

44

5 . G a s t r i c u l c e r and c a r c i n o m a .

48

6.

SI

Secondary o p e r a t io n s .

7. L a t e d e a t h s due t o p e p t i c u l c e r a t i o n .

56

PART I V . D iscu ssion . 1. General r e s u l t s .

68

2. P y l o r ic s t e n o s i s .

63

3. G a s t r i c u l c e r .

68

4 . Duodenal u l c e r .

69

5.

The p l a c e o f g a s t r o - e n t e r o s t o m y i n t h e treatm ent o f p e p t i c u l c e r a t i o n .

*70

*

6 . The modus o p e r a n d i .

73

G e n e r a l Summary.

75

A c k n o w le d g m e n t .

, 78

R eferences.

79

-

1

-

INTRODUCTION. One o f t h e more p r e s s i n g p r o b l e m s o f t o d a y i s p ep tic u lc e r a tio n . su fferin g,

state

that o f

W h e t h e r m e a s u r e d i n t e r m s o f human

economy o r h o s p i t a l

one o f c o n s i d e r a b l e m agnitude.

s e r v i c e s t h e problem i s

A l a r g e amount o f r e s e a r c h

h a s b e e n a p p l i e d t o t h e s u b j e c t , w i d e n i n g o u r Knowledge o f t h e n o r m a l and a b n o r m a l s t o m a c h and duodenum and o f t h e "ulcer** p a tien t.

D espite f i f t y years of

r e s e a r c h th e problem s t i l l

ex ists. O f t h e many l i n e s o f i n v e s t i g a t i o n w h i c h h a v e b e e n follow ed,

one o f t h e more t e d i o u s and ,

valu ab le,

h a s been t h e a s s e s s m e n t o f the e f f e c t o f v a r i o u s

forms o f tr e a tm e n t. typ es o f treatm ent, reported r e s u ltin g

at the

same t i m e , more

A l a r g e number o f r e v i e w s o f d i f f e r e n t b o t h s u r g i c a l and m e d i c a l ,

h a v e been

i n t h e a b a n d o n i n g o f t h e u n s u c c e s s f u l and

p erseveran ce in the m o r e - o r - le s s s u c c e s s f u l . The v o g u e f o r some t y p e s o f t r e a t m e n t was s h o r t - l i v e d ; i n o t h e r s d i s a f f e c t i o n o f t h e a d v o c a t e s h a s be en a more g r a d u a l p r o c e s s and o f t e n w i t h c o n s i d e r a b l e b i g o t r y on t h e p a r t o f t h e a n t a g o n i s t s and p r o t a g o n i s t s .

The o p e r a t i o n o f

g a s t r o ^ e n t e r o s t o m y h a s been a s t r i k i n g e xam p le o f t h i s p r o c e s s . I t i s n otew orthy th a t in 1926,

the op era tio n ,

a f t e r twenty

y e a r s a p p l i c a t i o n , w a s h a i l e d by e m i n e n t a u t h o r i t i e s i n g lo w in g terms as w hich/

such

"There i s p r o b a b l y no o p e r a t i o n i n s u r g e r y

-

2

-

w h i c h h a s a d d e d more t o t h e

sum o f human h a p p i n e s s t h a n

g a s t r o - j e j u n o s t o m y " ( S i r D’A r c y Po w e r ) and HI am an a r d e n t and a s a n g u i n e a d v o c a t e o f t h i s o p e r a t i o n t h a n w h i c h I t h i n k t h e r e i s none in a l l (L o r d M o y n i h a n ) .

It

s u r g e r y more c o m p l e t e l y s a t i s f a c t o r y " is

in d ee d rem arkable to f i n d ,

fu r th e r period o f tw enty y e a r s ,

the

same o p e r a t i o n

to a lm o s t g e n e r a l c r i t i c i s m amounting in v itu p eration .

after a subjected

some i n s t a n c e s t o

T h e r e may be many r e a s o n s f o r t h i s c h a n g e .

The t y p e o f u l c e r b e i n g d e a l t w i t h may h a v e become more s e v e r e o r t h e u l c e r b e a r i n g p a t i e n t s may h a v e become l e s s The i n c i d e n c e o f t h e d i s e a s e h a s i n c r e a s e d .

It

resista n t.

i s also

p o s s i b l e t h a t th e r e s u l t s f o l l o w i n g g a s t r o - e n t e r o s t o m y were n e v e r so g o o d a s r e p o r t e d and w e r e n e v e r s u f f i c i e n t l y bad t o ea rn t h e o p e r a t i o n i t s p r e s e n t r e p u t a t i o n . v ic is s it u d e s of gastro-enterostom y

At l e a s t t h e

s h o u l d be remembered a s a

c o r r e c t i v e in the l i g h t o f the alm ost e q u a lly g lo w in g r e p o r t s w h i c h a t t e n d t h o s e o p e r a t i v e p r o c e d u r e s w h i c h a r e now r e p l a c i n g it. G astro-enterostom y s t i l l w ith in

the p a st

fiv e years,

advocates.

Indeed,

a s a r e s u l t o f some d i s i l l u s i o n m e n t

in o th e r forms o f tr e a tm e n t, the op era tio n .

has i t s

I t was f e l t ,

t h e r e h a s b e e n r en ew e d i n t e r e s t therefore,

in

th a t a review o f the

l o n g - t e r m r e s u l t s was n e c e s s a r y t o a s c e r t a i n

e s p e c i a l l y what

p la c e t h i s procedure has in the treatm ent o f p e p t ic u l c e r a t i o n and/

-

and t o f i n d what e f f e c t o f u lcer,

etc.

3

-

such f a c t o r s as age,

h a v e on t h e r e s u l t s .

sex,

ch ron icity

T h e re w as a l s o t h e

p o s s i b i l i t y th a t the e x t e n s iv e a p p lic a t io n o f th e o p e r a tio n , v i e w e d a s an e x p e r i m e n t on t h e human s u b j e c t , e v e n a f l i c k e r o f l i g h t on e t i o l o g y .

m i g h t th ro w

-

4

-

EABL-JL* 1.

H istorical

I t i s now h a l f a c e n t u r y s i n c e Doyen f i r s t p e r f o r m e d , a g a stro -en tero sto m y f o r duodenal u lc e r a t io n .

S in ce then th e

o p e r a t i o n h a s be en p e r f o r m e d i n n u m e r a b l e t i m e s . were e n t h u s i a s t i c

and up t o 1 93 0 i t

c o n f i d e n t l y em ployed.

E arly claim s

was t h e p r o c e d u r e

The p o p u l a r i t y w a s b a s e d on t h e

s u p p o s e d l y h i g h i n c i d e n c e o f go o d r e s u l t s , p e r f o r m a n c e and l o w m o r t a l i t y .

tech n ical

ease o f

E n t h u s i a s m g a v e way t o d o u b t

a s t h e f r e q u e n c y o f g a s t r o - j e j u n a l u l c e r a t i o n became i n c r e a s i n g l y recognised.

T h e r e a f t e r , more and more s u r g e o n s f e l l

w ith e a r ly advocacy o f B i l l r o t h , gastric

resection

in l i n e

F i n s t e r e r and Lewi sohn f o r

in duodenal a3 w e l l as g a s t r i c u l c e r a t i o n .

Today, g a s t r o - e n t e r o s t o m y h a s b e e n l a r g e l y

su p e r se d e d by th e

more r a d i c a l o p e r a t i o n i n t h e more s p e c i a l i s e d c l i n i c s ; n e v e r t h e le s s the short c i r c u i t o p era tio n

still

hold s favour

i n a few c l i n i c s and i s t h e p r o c e d u r e g e n e r a l l y p r e f e r r e d b y the o c c a sio n a l g a s t r ic

surgeon.

The e a r l i e r g a s t r e c t o m i e s ,

though red u cin g th e i n c i d e n c e o f secondary u l c e r a t i o n , no g u a r a n t e e o f p e r m a n e n t c l i n i c a l c u r e .

carried

B a lfo u r (1944)

estim ated 9 per cen t recurrence o f u lc e r a f t e r p a r t i a l gastrectom y w h ile R ein h o ff (1945)

found 8 p e r c en t o f c h r o n ic

duodenal u l c e r s c o m p letely r e s i s t a n t to p a r t i a l g a str ec to m y . The o p e r a t i o n h a s , resectio n ,/

accord in gly,

in c r e a s e d in the e x t e n t o f th e

-

5

-

r e s e c t i o n , - t h e d i f f i c u l t y o f i t s p e r f o r m a n c e and h a s c a r r i e d a m o r t a l i t y , w hich, 5 per cen t.

o n l y in th e most s k i l l e d hands,

Though t h e p r o t e c t i o n a g a i n s t

i s now w e l l - n i g h f u l l , new s y n d r o m e s , w h i c h ,

Vi s i c k (1S48),

is

l e s s than

secondary u lc e r a t io n

th e o p e r a t io n has produced

as y et incom p letely

stud ied ,

are in a

considerab le percentage o f c a se s d is a b lin g . More r e c e n t l y ,

v a g o t o m y h a s b e e n add ed t o t h e r e p e r t o i r e

i n an a t t e m p t t o p r o d u c e more c e r t a i n

c u r e by a l e s s f o r m i d a b l e

procedure.

The e a r l y e n c o u r a g i n g r e s u l t s h a v e n o t be en

sustained.

R e c u r r e n c e s do o c c u r .

ation s,

There a r e o t h e r c o m p li c ­

f o r e x a m p l e g a s t r i c r e t e n t i o n and d i a r r h o e a .

come g a s t r i c

reten tion ,

vagotomy h a s r e c e n t l y been

To o v e r ­

c om bin ed w i t h

g a s t r o - e n t e r o s t o m y , mak ing t h e t r e a t m e n t o f p e p t i c u l c e r by v a g o t o m y more d i f f i c u l t Such,

to a s s e s s .

th en h a s been t h e broad t r e n d o f s u r g i c a l t r e a t m e n t

i n p e p t i c u l c e r a t i o n and i t

c a n n o t be c l a i m e d t h a t

tr e a tm e n t has been e m in e n t ly s a t i s f a c t o r y . a p p r a i s e vagotomy, It

is

It is

su rgical too e a r l y to

e s p e c i a l l y c o m bi n ed w i t h g a s t r o - e n t e r o s t o m y .

p r o b a b l y t o o e a r l y t o e v a l u a t e “m e a s u r e d r a d i c a l

g a s t r e c t o m y 1* i n v i e w o f t h e s e q u e l a e , n o t a l w a y s t r a n s i e n t , w h i c h may o c c u r .

A fter f i f t y years i t

seems t i m e l y to tak e

s t o c k o f what h a s b e e n a c h i e v e d by t h e o p e r a t i o n o f g a s t r o ­ enterostom y. Thr ou gh ou t t h e c h a n g i n g f a s h i o n o f g a s t r i c have/

surgery there

-

6

-

h a v e b e e n t h o s e who h a v e c h a m p io n e d t h e c a u s e o f g a s t r o ­ e n t e r o s t o m y and who h a v e c l a i m e d by f i g u r e s o r i m p r e s s i o n t h a t t h e r e s u l t s a r e n o t a s b ad a s h a v e b e e n c o n s i s t e n t l y asserted.

R e s u l t s up t o 1 9 3 5 w e r e g e n e r a l l y f a v o u r a b l e ,

and t h e i n c i d e n c e o f p r o v e d and s u s p e c t e d u l c e r a t i o n w a s sm all.

In t h i s c o u n t r y W ilicie ( 1 9 3 4 ) , Walton (1 9 3 4 )

Moynihan ( 1 9 3 4 )

and

reported recurrence r a te s o f 3.5 per cen t,

3 . 4 p e r c e n t and 1 p e r c e n t r e s p e c t i v e l y . i n v e s t i g a t i o n s by L u f f (1 9 2 8 )

Two l a r g e

scale

and G a r n e t t W r i g h t ( 1 9 3 5 )

r e v e a l e d e v i d e n c e o f r e c u r r e n c e i n 2 . 8 p e r c e n t and 8 p e r cent r e s p e c tiv e ly . reports.

I n A m e r i c a t h e r e w e r e mary f a v o u r a b l e

F o r e x a m p l e S t . John ( 1 9 3 0 )

(1930 ) 4 per cen t,

6.9 per cen t,

H artw ell e t a l (1930)

B alfour

4 p e r c e n t and

E l i a s o n and J o h n s o n ( 1 9 3 6 ) 8 . 5 p e r c e n t o f u n s a t i s f a c t o r y r e s u l t s a r e r e p r e s e n t a t i v e o f many.

B a r b e r and B o g a t k o ( 1 9 3 8 )

r e v i e w i n g t h e i r own r e s u l t s i n 1 5 3 c a s e s and t h e r e s u l t s f r o m p u b l i s h e d p a p e r s o f v a r i o u s A me ri can S u r g i c a l c l i n i c s a m o u n ti n g t o a l m o s t 1600 c a s e s f o u n d an i n c i d e n c e o f m a r g i n a l u l c e r a t i o n r a n g i n g b e tw e e n 1 . 6 -

7 per c en t.

As i n m o s t o f t h e s e p a p e r s

th e le n g t h o f fo llo w - u p i s l o o s e l y d e sig n a te d - in t h i s in s t a n c e b e t w e e n 1 and 17 y e a r s .

The number o f c a s e s f o l l o w e d 5 ,

15 y e a r s i s n o t s t a t e d .

At t h e same t i m e d i s s e n s i o n was

10 and

e v i d e n t i n t h e r e p o r t e d r e s u l t s o f M a r s h a l l and K i e f f e r ( 1 9 3 4 ) 24 p e r c e n t , L e w i s o h n ( 1 9 2 5 ) c en t./

34 p e r c e n t and B er g ( 1 9 3 0 )

30 p e r

-

cent.

7

-

S i n c e t h e n p u b l i s h e d r e s u l t s due t o w a n i n g e n t h u s i a s m

and l o n g e r f o l l o w - u p h a v e b e e n g e n e r a l l y l e s s f a v o u r a b l e and g a s t r e c t o m y h a s more a nd more g a i n e d g r o u n d a s t h e p r o c e d u r e o f c h o ic e in the s u r g ic a l treatm ent o f p e p tic u l c e r a t i o n . T h is p r e f e r e n c e h a s n o t been unanimous.

D arling

(1939) has

q u e s t io n e d th e p o l i c y o f abandoning g a s t r o - e n t e r o s t o m y ,

an

o p e r a t i o n w h i c h he c l a i m s c a r r i e s an o p e r a t i v e m o r t a l i t y o f 1 per cent,

fo r gastrectom y w ith a m o r ta lity o f 6 per cen t,

b eca u se 4 p e r cent d e v e lo p g a s t r o - j e j u n a l u l c e r a t i o n . (1944)

follow -up

ju st

W alton’ s

shows an i n c i d e n c e o f 4 p e r c e n t g a s t r o - j e j u n a l

u l c e r a t i o n a f t e r p o s t e r i o r g a s tr o -e n te r o s to m y f o r duodenal u l c e r w ith o r w ith out

s t e n o s i s and r e s e r v e s p a r t i a l g a s t r e c t o m y

f o r t h e 4 p e r c e n t o f p a t i e n t s who d e v e l o p j e j u n a l u l c e r subsequently.

Heuer e t a l (1 9 4 2 )

and, more r e c e n t l y ,

Cooper

( 1 9 4 8 ) h a v e r e v i e w e d t h e p a s t e x p e r i e n c e o f t h e New York H o s p i t a l i n g a s t r o - e n t e r o s t o x o y and t h e i r to

t h e v i e w t h a t ”g a s t r o - e n t e r o stomy i s

r e s u lt s lend them selves a u s e f u l and* o f t e n

c u r a t i v e procedure w hich has a d e f i n i t e p la c e in the r e p e r to r y of gastric

surgery”.

I t s p la c e in th e treatm ent of organic p y lo r ic h a s seldom been d i s p u t e d . review s u b s ta n tia te

R ei d and Marcus ( 1 9 4 8 )

that b e l i e f .

sten osis in t h e i r

They r e p o r t e d 98 p e r c e n t

s a t i s f a c t o r y r e s u l t s in p a t i e n t s a l i v e over ten y ea rs a f t e r operation.

Thomson ( 1 9 4 8 )

e n th u sia stic./

and P a t e y ( 1 9 4 8 ) a r e l e s s

-

en th u sia stic.

Indeed,

8

-

a s l o n g ago a s 1 9 3 5 G a r n e t t W r i g h t c a s t

d o u b t on t h i s b e l i e f . 2.

C r i t i c a l o b s e r v a t i o n s on t h e l i t e r a t u r e .

The l i t e r a t u r e on t h e

su b jec t i s volum inous.

m ainly w it h th e r e s u l t s o f the o p e r a tio n , s h o r t c i r c u i t on g a s t r i c

the e f f e c t

s e c r e t i o n and m o t i l i t y ,

a p p r a is a l o f th e probable c a u s e s o f f a i l u r e . the opin ion th at l i t t l e

It

d eals

o f the

and an

The a u t h o r i s o f

b e n e f i t woul d a c c r u e f r o m a d e t a i l e d

d i s c u s s i o n o f a h u nd r e d o r more r e v i e w s .

H ow ev er,

the

f o l l o w i n g c r i t i c a l o b s e r v a t i o n s a r e germ ane t o t h e p r e s e n t 1.

E x c lu d in g vagotomy,

th e r e s u l t s o f w hich have n o t be

a s s e s s e d o v er a s u f f i c i e n t l y long p erio d , litera tu re,

study.

the c o n tr o v e r s y in the

p e r t a i n i n g to th e s u r g i c a l treatm en t o f p e p t ic u l c e r ,

h i n g e s on t h e r e l a t i v e m e r i t s o f g a s t r o - e n t e r o s t o m y and g a s t r e c ­ tomy.

Among t h e a d v a n t a g e s o f t h e f o r m e r a r e i t s

lo w m o r t a l i t y

and f r e e d o m from th o 3e s yn dr om e s w h i c h f o l l o w g a s t r e c t o m y , a s "dumping” , p o s t - p r a n d i a l h y p o g l y c a e m i a ,

f a i l u r e o f the

p a t i e n t t o g a i n w e i g h t and m i c r o c y t i c a n a e m i a .

I t s ch ief d is­

advantage i s th e in c id e n c e o f seco n d a ry u l c e r a t i o n , e s t i m a t e d a t 4 - 40 p e r c e n t .

o f stomal u l c e r a t i o n .

o p e r a t i v e management i s dangerous/

variou sly

Further disa d v a n ta g es o f

gastrectom y are the h ig h er f a t a l i t y sm all,

such

r a t e and a r i s k ,

though

When stomal u l c e r d o e s d e v e l o p i t s

c o n s i d e r a b l y more d i f f i c u l t

and

-

9

-

d an gerous than t h a t o f j e j u n a l u l c e r f o l l o w i n g g a s t r o - e n t e r o s t o m y . Moreover,

t h e c o n v a l e s c e n c e a f t e r t h e more r a d i c a l p r o c e d u r e i s

l o n g e r and more u n c o m f o r t a b l e . 2.

Throughout th e l i t e r a t u r e p e r t a i n i n g to th e

controversy,

close

atten tion

i s p a i d to t h e o p e r a t i v e m o r t a l i t y

f i g u r e s and i n many c a s e s t h e c o m p a r i s o n i s n o t w i t h o u t d a n g e r . M o r t a l i t y f i g u r e s w ith o u t th e age d i s t r i b u t i o n c a n n o t b e f a i r l y c om pa r e d.

o f the p a tie n ts

G a s t r e c t o m y p e r f o r m e d f o r un­

c o m p l i c a t e d p e p t i c u l c e r i n p a t i e n t s u n d e r 40 y e a r s o f a ge c a r r i e s a v e r y low m o r t a l i t y .

In th e f i f t i e s ,

s i x t i e s and

s e v e n t i e s t h e o p e r a t i o n i s h a z a r d o u s and i t i s i n t h e s e a g e groups, that

when t h e i n c i d e n c e o f r e c u r r e n t h a e m o r r h a g e i s g r e a t e s t ,

resection

s e r i e s are,

i s most i n d i c a t e d .

therefore,

Many g a s t r o - e n t e r o s t o m y

l o a d e d i n t h e o l d e r a g e g r o u p s and t h e r e

i s no do u bt t h a t t h e f a t a l i t y

r a t e i n g a s t r e c t o m y i n many s e r i e s

h a s b e e n im p ro v e d by t h e e x c l u s i o n o f t h e e l d e r l y . h a s b e e n s t a t e d by A i r d ( 1 9 4 9 )

Indeed,

th a t the g e n e r a l f a t a l i t y

it

rate

a f t e r g a s t r e c t o m y f o r d u o d e n a l u l c e r i n t h i s c o u n t r y c a n n o t be much l e s s t h a n 10 p e r c e n t .

Moreover,

a g e a l o n e i s n o t an

a c c u r a t e m e a s u r e o f a p a t i e n t 1s f i t n e s s t o w i t h s t a n d an e x t e n s i v e operation,

a n d wh e r e h i s f i t n e s s i s i n do u b t t h e n a t u r a l t e n d e n c y

i s t o e m p lo y a l e s s f o r m i d a b l e p r o c e d u r e .

Caution i s ,

f o r e , n e c e s s a r y i n c om pa r in g m o r t a l i t y r a t e s . 3 ./

there­

3. u n iform ity

A study o f the l i t e r a t u r e

r e v e a ls also a lack of

in th e rep orting o f r e s u l t s .

C om p ar is on o f t h e

r e s u l t s o f two s e r i e s o f c a s e s o f p e p t i c u l c e r a t i o n

t r e a t e d by

g a s t r o - e n t e r o s t o m y and g a s t r e c t o m y o r any o t h e r t h e r a p y c a n , therefore,

be f a l l a c i o u s .

r e p o r tin g r e s u l t s i s to o p e r a t e d up on,

One o f t h e m o s t common m e t h o d s o f

state,

f o r example,

one t o t e n y e a r s a g o ,

o f p o o r r e s u l t s was Y.

th at in X c a s e s

the percentage in c id en ce

T his statem ent i s p e r f e c t l y a c c u r a te ,

b u t on e s e r i e s may c o n s i s t l a r g e l y o f s h o r t f o l l o w - u p c a s e s and another a large proportion o f c a s e s fo llo w e d f o r a lo n g er perio d . C o m p a r is o n o f two s e r i e s o r two m e t h o d s o f t r e a t m e n t on t h i s b a s i s w o u l d be i n a c c u r a t e . to

A n o t h e r me th o d commonly e m p l o y e d i s

s t a t e th e average fo llo w - u p p e r io d f o r the group o f c a s e s ,

thus,

f o r e x a m p l e , X c a s e s s u r v i v i n g o p e r a t i o n and f o l l o w e d f o r

an a v e r a g e p e r i o d o f 7 . 5 y e a r s had an i n c i d e n c e o f r e c u r r e n c e o f Y per cent.

The s t a t e m e n t i m p l i e s t h a t X c a s e s w e re f o l l o w e d

7 . 5 y e a r s w h i c h i s n o t t r u e and c o m p a r i s o n w i t h a s e r i e s o f e q u a l a v e r a g e f o l l o w - u p p e r i o d may be i n a c c u r a t e .

One g r o u p may

c o n t a i n a h i g h p r o p o r t i o n o f c a s e s f o l l o w e d o n e y e a r and a n o t h e r w ith c a s e s fo llo w ed fourteen y e a rs.

The o n l y a c c u r a t e me th od o f

r e p o r t i n g r e s u l t s and t h e m e th od w h i c h a l l o w s o f f a i r c o m p a r i s o n o f o n e s e r i e s and a n o t h e r i s

t o g i v e t h e p o o r r e s u l t s and c a s e 3

follow ed f o r each year a f t e r o p era tio n .

These a re c o n v e r t e d to

p e r c e n t a g e s and r e c o r d e d a s an a c c u m u l a t i n g p e r c e n t a g e g i v i n g a curve/

curve which r e p r e s e n t s th e e n t i r e e x p e r ie n c e f o r e a c h y e a r o f follow -u p . 4.

T h i s i s t h e me th od u s e d i n

the p r e s e n t stu d y ,

In view o f th e r e la p sin g nature o f th e d is e a s e ,

a

f e w a u t h o r s and i n p a r t i c u l a r C o o p e r ( 1 9 4 7 ) h a v e t a k e n i n t o a c c o u n t r e l a p s e s and r e m i s s i o n s on a y e a r t o y e a r "basis - a c a s e may be a p o o r r e s u l t o n e y e a r and a g o o d r e s u l t f o r t h e n e x t fiv e years.

T h i s meth od no d o u b t g i v e s a more a c c u r a t e p i c t u r e

and a t t h e same t i m e a b r i g h t e r p r o s p e c t th a n t h e c u m u l a t i v e meth od b u t o n e o f t h e c h i e f p o i n t s o f i n v e s t i g a t i o n

in t h i s

p r e s e n t r e v i e w w a s t h e a b i l i t y o f g a s t r o - e n t e r o s t o m y t o "c ur e" p ep tic u lc e r a tio n . n o t cured,

T he re i s no do u b t t h a t many p a t i e n t s ,

though

d e r i v e d b e n e f i t by h a v i n g l o n g e r r e m i s s i o n s th a n

before op eration . Most p r e v i o u s p a p e r s h a v e d e a l t w i t h r e l a t i v e l y resu lts.

The o b j e c t o f t h i s

believin g,

a s Lord Moynihan s t r e s s e d i n h i s . H u n t e r i a n L e c t u r e i n

1923, knew".

study i s

short-term

to p resen t lon g-term r e s u l t s

t h a t " t h e y e a r s c e r t a i n l y t e a c h much t h a t t h e d a y s n e v e r

PART

II.

PARTICULARS OF SURVBY. 1.

CLINICAL MATERIAL. The m a t e r i a l i n t h i s r e v i e w c o n s i s t s o f 330 p o s t e r i o r

g a s t r o - e n t e r o s t o m i e s performed f o r p e p t i c u l c e r a t i o n d u rin g th e 14 y e a r s b e t w e e n 1 s t J a n u a r y ,

1 9 2 4 and 3 1 s t D e ce m b e r ,

1937,

A ll

c a s e s w e r e u n d e r t h e c a r e o f one s u r g i c a l u n i t i n t h e W e s t e r n Infirm ary,

Glasgow.

A l l p a t i e n t s came fro m G l a s g o w and

adjacent d i s t r i c t s . 2.

OPERATION AND POST-0PBRATIV5 CARS. The i n d i c a t i o n

to m edical treatm ent,

f o r o p e r a t i o n wa s g e n e r a l l y l a c k o f r e s p o n s e i n f l u e n c e d by t h e b e l i e f ,

a t th a t tim e th a t

th e r e s u l t s f o l l o w i n g g a s t r o - e n t e r o s t o m y were good.

This ex ­

p l a i n s t h e c o m p a r a t i v e l y l a r g e number - n a m e l y 6 6 , w i t h h i s t o r i e s o f only 1 - 4

years duration.

In 6 c a s e s th e g a s t r o - e n t e r o 3 t o m y was performed a t th e tim e o f c lo s u r e o f a p e r f o r a t i o n .

I n two c a s e s ,

gastro­

e n t e r o s t o m y w i t h l i g a t i o n o f a d j a c e n t v e s s e l s was p e r f o r m e d b e c a u s e o f c o n t i n u e d b l e e d i n g w h i c h had f a i l e d t o r e s p o n d t o c o n serv a tiv e treatm ent.

The r e m a i n d e r w e r e e l e c t i v e o p e r a t i o n s .

The o p e r a t i o n s w e r e p e r f o rnied by t h e s e n i o r s u r g e o n and h i s f i r s t a ssista n t.

Most o f t h e p a t i e n t s w e r e d i s c h a r g e d a f t e r a s t a y i n

h o s p i t a l o f 21 t o 28 d a y s . C o n v a l e s c e n t Home.

A fe w r e c e i v e d f u r t h e r c a r e i n a

A ll p a tien ts,

a f t e r d i s c h a r g e , had a t t e m p t e d

- 13 to f o ll o w th e d ie t a r y i n s t r u c t i o n s months,

t h e m a j o r i t y f o r some

h u t f e w p e r s i s t e d f o r more t h a n a y e a r ,

d i e t i n g was s p o r a d ic ,

T hereafter,

u s u a l l y during p e r io d s o f r e l a p s e .

Many

had t a k e n a d v a n t a g e o f t h e w a r t i m e p r i o r i t y i n m i l k and e g g s . A n ta c id powders were tak en a c c o r d in g to

sym ptoms.

Almost a l l

t h e p a t i e n t s had made on e r e t u r n v i s i t t o t h e h o s p i t a l h u t f e w had p a i d more t h a n t h r e e v i s i t s .

T hereafter,

e x c e p t t h o s e who

s u f f e r e d c o m p l i c a t i o n s s u c h a s h a e m o r r h a g e and p e r f o r a t i o n o r who w e r e r e - a d m i t t e d t o t h i s and o t h e r i n s t i t u t i o n s f o r m e d i c a l and s u r g i c a l t r e a t m e n t ,

t h e m a j o r i t y had h e e n u n i n f l u e n c e d hy

fu rth er in te n siv e treatm ent.

They p r o v i d e ,

therefore,

a series

o f p e p t i c u l c e r s m o d i f i e d o n l y hy a s h o r t - c i r c u i t o p e r a t i o n making p o s s i b l e an a s s e s s m e n t o f t h e e f f e c t o f g a s t r o - e n t e r o s t o m y p e r se a s a tr e a tm e n t in p e p t i c u l c e r a t i o n . 3.

FOLLOW-UP. An a t t e m p t w a s made t o t r a c e a l l

th em f o r e x a m i n a t i o n . were i n t e r v i e w e d .

t h e s u r v i v o r s and r e c a l l

1 6 5 p a t i e n t s w e r e t r a c e d h y l e t t e r and

21 now a t a d i s t a n c e i n t h e U.K. o r a b r o a d

c o u l d he c o n t a c t e d o n l y hy 1 e t t e r - q u e s t i o n n a i r e . o f t h e Almoner, ation s,

Red G r o s s w o r k e r s and o t h e r v o l u n t a r y o r g a n i s ­

50 w e r e t r a c e d and f o u n d t o ha ve d i e d .

a v a i l a b l e from t h e i r r e c o r d s ,

rela tiv es,

c e r t i f i c a t e s a l l o w e d o f some a s s e s s m e n t , The r e m a i n i n g 70 ,

despite a l l

o f change o f a d d r e s s . area/

w ith the h elp

effort,

The i n f o r m a t i o n

f a m i l y d o c t o r s and d e a t h alb eit

secondhand.

r e m a in e d u n t r a c e d b e c a u s e

Many o f t h e s e had h e e n r e s i d e n t i n an

14

-

-

a r e a w h i c h had s u f f e r e d fr o m '•enemy a c t i o n " . o f c a s e s t r a c e d w a s 260 o u t o f t h e 3 3 0 ,

i.e .

The t o t a l number 78.7 p er cen t.

The i n v e s t i g a t i o n w a s c a r r i e d o u t d u r i n g 1 9 4 8 . A d ifficu lty

a r i s i n g in most f o llo w - u p i n v e s t i g a t i o n s i s

the d is p o s a l o f " lo st" c a s e s .

The r a t i o o f go o d t o p o o r r e s u l t s

i n t h i s g r o u p can rem ain o n l y a m a t t e r o f o p i n i o n ,

though C ooper

(1948) b e l i e v e s th e r e i s

support f o r the view th a t th e r a t i o

t h e same i n t h e l o s t a s

in the fo llo w e d group.

Mage ( 1 9 4 3 ) w e re o f com plicated

H o l l a n d e r and

t h e same o p i n i o n t h o u g h t h e y p r o c e e d e d t o a

s t a t i s t i c a l method o f a n a l y s i s b a s e d upon maximum and

minimum p e r c e n t a g e s o f f a i l u r e s f o r author i s o f the o p in ion th a t fo r reasons stated , is

is

it

each f o llo w - u p y e a r .

The

s i n c e t h e 70 c a s e s w e r e u n t r a c e d

i s a f a i r p r e s u m p t i o n t h a t t h e 260 t r a c e d

a r e a s o n a b le sample.

The u n t r a c e d c a s e s a r e ,

therefore,

not

considered. Of t h e 2 6 0 , St om ac h,

8

a r e known t o h a v e d i e d o f C a r ci n o m a o f

3 o f th esew ith in 2 y ea rs o f o p era tio n .

i n c l u d e d i n t h e a s s e s s m e n t an d f a i l u r e c u r v e a s i t w hich the o p e r a tio n

carries.

It

These 3 a r e is

a risk

i s not alw ays p o s s i b l e a t

o p e r a t i o n t o d e t e r m i n e t h e e x a c t n a t u r e o f a m as s a t t h e p y l o r u s o r t o e s t a b l i s h t h e i n n o c e n c e o f a g a s t r i c u l c e r e s p e c i a l l y where rad iological

f in d in g s su g gest sim ple u l c e r a t i o n .

I t is 'p r o b a b ly in a ccu ra te to claim t h i s "follow -up".

The i d e a l " f o l l o w - u p " demands t h a t t h e p a t i e n t be

seen a t r e g u l a r i n t e r v a l s ; or/

study a s a

t h a t t h e p a t i e n t be s e e n d u r i n g h i s

or her p e r io d s o f com plaint; T h is study i s , first little

therefore,

t h a t a l l c a s e s s h o u l d be t r a c e d .

d eficien t.

Many w e r e s e e n f o r t h e

t i m e 11 - 2 2 y e a r s a f t e r t h e e v e n t . more t h a n a r e c a p i t u l a t i o n ,

but i t

It

is,

accordin gly,

i s as accurate as a

p r e v i o u s h i s t o r y can be and i n many c a s e s more s o ,

since

d o c u m e n t a r y e v i d e n c e w a s o b t a i n e d from o t h e r c e n t r e s w h e r e t h e p a t i e n t s had r e p o r t e d .

T his d e f i c i e n c y ,

however,

has the

advantage th a t the s e r i e s r e p r e s e n t s p e p t ic u l c e r a t i o n t r e a t e d by g a s t r o - e n t e r o s t o m y w i t h o u t s u p e r a d d e d m e d i c a l t r e a t m e n t o f more t h a n s p o r a d i c i n t e n s i t y . The d i s t r i b u t i o n o f t h e c a s e s by o p e r a t i o n y e a r and t h e i r p la c e s in t h i s fo llo w -u p are

shown i n T a b l e I .

th e c a s e s according to d ia g n o s i s . Table I . /

Table I I

lists

- 16 TABLEI I . Year

m

DISTRIBUTION OF CASES BY YEAR OF OPERATION

O perative Deaths

Traced Dead

Traced A live

Untraced

T otal.

1924

2

2

2

4

10

1925

0

6

2

1

9

1926

3

10

2

6

21

1927

1

9

1

7

18

1 928

2

12

5

7

26

1929

2

14

1

4

21

19 3 0

5

17

5

6

33

19 3 1

3

22

5

6

36

1932

1

20

2

6

29

1933

2

17

7

5

31

1 934

0

21

8

5

34

1935

1

8

6

5

20

1936

2

14

0

3

19

1937

0

14

4

5

23

24

186

50

70

330

TABLE I X . - DI STRIBtJTIOB OE OASES BY DIAGNOSIS. D iagnosis

O perative D eaths

Traced A live

Traced Dead

Untraced

T otal.

P yloric S ten osis

15

19

7

5

36

D .U.

15

156

30

61

262

G.U.

4

8

11

4

27

D .U . - G.U.

0

3

2

0

5

24

186

50

70

330

17

-

4.

-

ASSESSMENT OF RESULTS. Owing t o c i r c u m s t a n c e s b e y o n d t h e c o n t r o l o f t h e a u t h o r ,

Barium m e a l i n v e s t i g a t i o n was p o s s i b l e assessm ent o f the r e s u l t of com plications,

i s b a s e d e s s e n t i a l l y on symptoms,

further h o sp ita lisa tio n

and r a d i o l o g i c a l f i n d i n g s , fore,

in o n ly a few c a s e s ,

The h istory

fo r pep tic u lc e ra tio n

where a v a i l a b l e .

It

follow s,

there­

th a t th e u n s a t i s f a c t o r y r e s u l t s a r e proved o r s u s p e c te d

secondary u lc e r a t io n .

Though s t o m a l u l c e r i s p r o b a b l y n o t t h e

o n l y c a u s e o f c o n t i n u i n g p a i n and d y s p e p s i a a f t e r g a s t r o ­ enterostom y,

it

is,

by f a r ,

o u t by MOynihan ( 1 9 3 0 ) one,

t h e most common.

t h a t an u l c e r ,

It

h a s been p o i n t e d

e i t h e r t h e o l d one o r a new

i s t h e c a u s e o f p a i n and ha e m o r r h a g e w h i c h d e v e l o p s a f t e r a

short c ir c u it in g op eration . The r e s u l t s h a v e been d i v i d e d i n t o u n sa tisfa cto ry .

s a t i s f a c t o r y and

T hos e e n t i r e l y f r e e from symptoms and t h o s e i n

whom i n d i g e s t i o n w as n o t i n e x c e s s o f t h a t £o w h i c h n o r m a l man i s h e i r , were c o n s id e r e d

sati sfa c to ly ,

The u n s a t i s f a c t o r y a r e t h o s e

who a t an y t i m e s i n c e o p e r a t i o n ( 1 ) h a v e had p a i n o f " u l c e r " t y p e ( 2 ) h a v e s u f f e r e d fro m h a e m a t e m e s i s o r m e l a e n a (3 ) have been h o s p i t a l i s e d

fo r m edical or s u r g ic a l

treatm ent o f p e p t ic u lc e r a tio n ( 4 ) h a v e o r h a v e had X - r a y e v i d e n c e o f m a r g i n a l u lc e ra tio n or reactivation u lcer. A s/

of the o r i g i n a l

-

As r e g a r d s m e l a e n a ,

18

-

o n l y t h o s e i n whom i t

caused a t l e a s t a

m in or d e g r e e o f c o n s t i t u t i o n a l u p s e t were c o n s id e r e d t o have b led .

L o s s o f w o r k i n g t i m e wa s n o t u s e d i n a s s e s s m e n t a s i t

w a s f o u n d t o be v a r i a b l e and t h a t many p a t i e n t s had c o n t i n u e d t o work though s u f f e r i n g f a i r l y

severe

symptoms.

The c a s e s

grouped a s u n s a t i s f a c t o r y were n o t a l l p o o r r e s u l t s . though n o t cured, these

b e n e f i t e d by t h e o p e r a t i o n .

r e s u l t s have been f u r t h e r graded in t o

Many,

A ccordin gly,

severe,

moderate

and m i l d . 5.

GRADES OF SEVERITY.

Severe:

P a i n a s s e v e r e o r more s e v e r e t h a n b e f o r e o p e r a t i o n . T h o s e who h a v e had c o m p l i c a t i o n s o r who h a v e r e q u i r e d fu r th e r o p eration because o f p e p tic u lc e r a t io n .

M oderate:Pain l e s s

s e v e r e and more e a s i l y c o n t r o l l e d by f o o d

and a l k a l i e s . M ild:

Pain,

s l i g h t and i n f r e q u e n t and w i t h d y s p e p s i a

(fla tu len ce, restrictio n

heartburn,

etc.)

requiring

d iet

and a l k a l i t h e r a p y a m ou nt in g t o

some

l i m i t a t i o n o f t h e n o r m a l mode o f l i f e . 6.

FAILURE CURVE. The o n s e t o f symptoms a f t e r o p e r a t i o n h a s b e e n d a t e d a s

a c c u r a t e l y a s p a t i e n t s can,

adm ittedly d i f f i c u l t ,

r e t r o s p e c t e x t e n d i n g 1 0 , 15 and 20 y e a r s . been/

in a

I n some c a s e s i t

has

been p o s s i b l e t o

c h e c k t h i s i n t h e r e c o r d s o f t h i s h o s p i t a l and

o f o t h e r h o s p i t a l s where t h e p a t i e n t s have been a d m itte d . The p e r c e n t a g e o f u n s a t i s f a c t o r y r e s u l t s i n e a c h f o l l o w - u p y e a r h a s been c a l c u l a t e d

s e p a r a t e l y f o r the th ree grou p s o f

p a t ie n t s - those in terview ed ,

t h o s e c o n t a c t e d by q u e s t i o n n a i r e

and t h o s e known t o h a v e d i e d .

The r e l a p s e r a t e i n e a c h g r o u p

b ein g r e a s o n a b ly comparable,

the percentage o f u n s a t is f a c t o r y

r e s u l t s per fo llo w -u p year f o r th e e n t i r e group o f p a t i e n t s t r a c e d ( e x c l u d i n g t h e i m m e d i a t e p o s t - o p e r a t i v e d e a t h s ) wa s c a l c u l a t e d and p l o t t e d

in a f a i l u r e curve.

F or the purpose o f t h i s study,

any p a t i e n t h a v i n g

w h i c h amount t o an u n s a t i s f a c t o r y r e s u l t i s f r om t h e o n s e t o f r e c u r r e n c e t h r o u g h t h e follow -up. recurrence,

That i s , t h e

c o n sid e re d as such

remaining y e a r s o f

c ur ve i s c h a r t e d on t h e b a s i s "o nce a

always a r e c u r r e n c e " .

o f t h e c u r v e f o r t h o s e who, i n 18 y e a r s f o l l o w - u p .

symptoms

e.g .

T h e r e h a s b e e n no m o d i f i c a t i o n h a v e had o n l y 4 y e a r s symptoms

S im ilarly,

t h o se c a s e s m o d i f i e d by

f u r t h e r s u r g i c a l or m e d ic a l tr e a tm e n t have been c o n s id e r e d f a i l u r e s fr o m t h e o n s e t o f

symptoms.

T h i s m e t h o d , no d o u b t ,

p r e s e n t s a more g lo o m y p i c t u r e t h a n a y e a r - t o - y e a r a s s e s s m e n t would, but i s elapsed

was f e l t

that,

sin ce operation,

i n v i e w o f t h e y e a r s t h a t had

t h e more s i m p l e meth od wa s a s u f f i c i e n t

t a x on t h e memory o f t h e p a t i e n t and l i m i t e d t h e im agination.

scope o f h i s

-

7.

20

-

RESULTS. The f a i l u r e c u r v e i s

s to w n i n F i g .

th e f a i l u r e curve are l i s t e d year,

1.

in Table I I I .

The f i g u r e s f o r A f t e r th e 20th

t h e nu m b e r s o b s e r v e d a r e s m a l l and a r e n o t i n c l u d e d .

C u r v e s f o r s e v e r e , m o d e r a t e and m i l d r e l a p s e s a r e a l s o F ig.

1 w i t h r e l e v a n t f i g u r e s in Table I I I .

TABU) I I I . /

shown i n

-

21

-

TABLE I I I . - TEE INCIDENCE OE SEVERE. MODEHATE. MILD- AND TOTAL RELAPSES PER FOLLOW-UP YEAR* R elapses. Moderate

F-U. Year

Cases Observed

1

236

21

8.89)

3(1.27)

1

0.43)

25(10.59)

2

228

33 1 4 . 4 7 )

10(4.38)

9

3.95)

52(22.80)

3

226

41 1 8 . 1 4 )

13(5.75)

16

7.08)

70(30.97)

4

224

40 1 7 . 8 5 )

13(5.81)

19

8 .4 8 )-

72(32.14)

5

221

43 1 9 . 4 5 )

1 5(6.79)

20

9.0 5 )

78(35.29)

6

220

43 1 9 . 5 4 )

1 8(8.18)

20

9.09)

8 l( 36.63)

7

216

46 2 1 . 2 9 )

17( 7 . 8 4 )

20

9.26)

83( 3 8 / 4 2 )

8

212

47 2 2 . 1 7 )

1 6(7.55)

20

9 .4 4 )

83(39.15)

9

212

49 2 3 . 1 1 )

17(8.02)

20

9.44)

86(40.57)

10

206

48 2 3 . 3 0 )

18(8.73)

23 1 1 . 1 6 )

89(43.20)

11

199

47 2 3 , 7 1 )

1 7(8.54)

22 1 1 .0 5 )

86(43.21)

12

182

43 2 3 .6 2 )

14(7.70)

19 1 0 . 4 4 )

7 6 (46.75)

13

163

40 2 4 . 5 4 )

13(8.00)

16

9.81)

69(42.33)

14

154

36 2 3 . 3 7 )

13(8.44)

16 1 2 . 2 1 )

65(42.20)

15

131

33 2 5 . 1 8 )

12(9.22)

13

9.92)

58(44.27)

16

111

26 2 3 . 4 2 )

11(9.91)

11

9.91)

48(43.24)

17

91

25 2 7 . 4 7 )

9(9.89)

9

9.89)

43( 4 7 . 2 4 )

18

70

19 2 7 . 1 4 )

9(12.85)

8 11.42)

36( 5 1 . 4 2 )

19

54

13 2 4 .0 7 )

9(16.48)

9 16.48)

31(57.40)

20

40

10 2 5 . 0 0 )

7(17.50)

8 20.00)

25(62.50)

Severe

M ild

T otal R elapses.

Fig

1.

Incidence

or "Iota,! , Soverae,.Moderate

and

7V\i]d

relaps'e^

-

22 -

< ------------ s> £ X X ^ 'p iC > U . T. -------

-

23

-

The o n s e t o f r e l a p s e s f o l l o w i n g on g a s t r o - e n t e r o s t o m y i s m o s t marked i n t h e f i r s t hut

3 years.

slow i n c r e a s e in i n c i d e n c e .

T hereafter,

th ere i s a steady

. From t h e 1 0 t h t o t h e 1 6 t h y e a r s ,

t h e c u r v e i s r e m a r k a b l y s t e a d y b e t w e e n 40 - 50 p e r c e n t . the 16th year, is

A fter

t h e r e i s a sharp r i s e but during t h i s p e r io d t h e r e

a r a p i d d e c l i n e i n t h e number o f p a t i e n t s ,

o n l y 40 h a v i n g b e e n

o b s e r v e d a t t h e 2 0 t h y e a r and t h e r i s e may be due p a r t l y t o c h a n c e . Furthermore,

it

i s d i f f i c u l t to be c e r t a i n th a t t h o s e l a t e o n s e t

r e l a p s e s w e r e n o t , i n f a c t , r e c r u d e s c e n c e s i n p a t i e n t s who had r e l a p s e d e a r l i e r and t h a t o n l y t h o s e a t t a c k s i n r e c e n t memory w e re noted.

The p a t i e n t s w e r e c l o s e l y

a s f a r a s c o u l d be a s c e r t a i n e d , in fa c t,

the f i r s t

q u e s t i o n e d on t h i s p o i n t and,

th o se l a t e o n set r e la p s e s were,

r e c u r r e n c e s o f sy mptoms.

C om pa r is on o f t h e

i n d i v i d u a l c u r v e s f o r s e v e r e , m o d e r a t e and m i l d r e l a p s e s , t h a t t h e e a r l y o n s e t r e l a p s e s a r e more s e v e r e .

reveals

The i m p r e s s i o n

i s a ls o g a in ed th at th e in c r e a s e in the u n s a t is f a c t o r y r e s u l t s a f t e r the 16th year o f fo llo w -u p i s

due m a i n l y t o l e s s

severe

relap ses. I t h as been s a i d , fo r'5 years,

there i s

that i f

a g a stro -en tero sto m y does w e ll

every chance o f i t s

c o n t i n u i n g t o do s o .

T h i s a p h o r i s m i s n o t c o n f i r m e d by t h e r e s u l t s o f t h e p r e s e n t study. first

A l t h o u g h t h e o n s e t o f r e l a p s e i s m o s t marked d u r i n g t h e 5 years,

th e r e a fte r th ere i s a gradual in crea se in in c id en ce .

Two c a s e s i n t h i s s e r i e s had t h e i r f i r s t in th e 19th y ea r o f fo llo w -u p , It/

recurrence o f

symptoms

one m o d e r a t e and t h e o t h e r m i l d .

24

-

I t w o u l d seem e s s e n t i a l , form o f t r e a t m e n t ,

-

therefore,

in t h e a s s e s s m e n t o f any

f o r peptic u lc e r t a tio n ,

su r g ic a l or m edical,

t h a t th e c a s e s should he f o ll o w e d f o r a t l e a s t

fiv e years.

At

t h e end o f t h a t p e r i o d t h e m a j o r r e c u r r e n c e w i l l h a v e b e e n recorded,

though as f a r as g a s tr o -e n te r o s to m y i s

concerned a

con sid erab le percentage rela p se a f t e r th at p eriod . Wright (1 9 3 5 ) n o t e d a s a r e s u l t o f t h e c o l l e c t i v e

G arnett enquiry o f the

F e l l o w s o f t h e A s s o c i a t i o n o f Surgeons t h a t in 25 p e r c e n t o f cases o f g a stro -jeju n a l u lceration ,

more t h a n 3 y e a r s e l a p s e d

b e f o r e t h e o n s e t o f symptoms. At t h e 2 0 t h y e a r o f f o l l o w - u p ,

6 2 .5 p e r c e n t would appear

to have r e l a p s e d to a v a r y in g d e g r e e . observed over t h i s period i s

sm all,

r o u n d f i g u r e s i t may be s a i d , 15 - 20 y e a r s 50 p e r c e n t h a v e to t h e i r p r e -o p e r a tiv e

However,

on ly 40,

t h e number

In approxim ate

th a t a f t e r a p e r io d o f between rem ain e d s y m p t o m - f r e e .

Compared

s t a t e 25 p e r c e n t a r e no b e t t e r o r w o r s e ,

1 2 . 5 p e r c e n t a r e im p ro ve d b u t

still

su ffe r con sid erab le d i s ­

a b i l i t y an d 1 2 . 5 p e r c e n t , t h o u g h e x p e r i e n c i n g d y s p e p s i a and p a i n o f s l i g h t degree, 8.

are markedly improved.

OPERATIVE MORTALITY. 24 p a t i e n t s d i e d a s a r e s u l t o f t h e o p e r a t i o n - a m o r t a l i t y

rate o f 7.2 per cen t. grouped. TAELB I V . /

Table IV.

The c a u s e s o f d e a t h can b e c o n v e n i e n t l y

25

TABLE I V .

- CAUSES OP DEATH IN IMMEDIATE POST-OPERATIVE PERIOD. CAUSE

NO. OF DEATHS

Chest c o m p lic a tio n s

7

C ardiac f a i l u r e

9

P erito n itis

4

Hae morrhage

4

Two o f t h e p a t i e n t s who d i e d f r o m ha e m o r r h a g e came t o o p e r a t i o n b e c a u s e o f c o n t in u e d haeraatemesis d e s p i t e m e d ic a l t r e a t m e n t and w e r e i n p o o r c o n d i t i o n .

The h a e m o r r h a g e c o n t i n u e d .

Two o f t h e d e a t h s fro m c a r d i a c f a i l u r e o c c u r r e d i n young p e o p l e during o p e r a t io n under c h lo r o fo r m a n a e s t h e s i a . r e s o u r c e s o f s u l p h - d r u g s and p e n i c i l l i n , , i t

w i t h p r e s e n t day

i s f e l t that

some o f

t h e d e a t h s from c h e s t c o m p l i c a t i o n s and p e r i t o n i t i s m i g h t n o t have occurred.

Indeed f o r comparison,

performed by th e

same u n i t

i n 56 g a s t r o - e n t e r o s t o m i e s

during th e 5 y e a r p e r i o d 1943 - 1947

t h e r e w e r e two d e a t h s - an o p e r a t i v e m o r t a l i t y o f 3 . 6 p e r c e n t . B o th o f t h e s e were c a s e s o f

severe haem atem esis in p a t i e n t s o ver

50 n o t r e s p o n d i n g t o m e d i c a l m e a s u r e s and o p e r a t e d on a s a l a s t resort.

It

i s doubtful i f g a stro -en tero sto m y has a p la ce in th e

trea tm en t o f con tin u ed o r m a ssiv e haem atem esis. The a g e d i s t r i b u t i o n ' o f t h e o p e r a t i o n f a t a l i t i e s i s i n T a b l e V. TABLE V . /

shown

-

26 -

TABLE V. - AGE DISTRIBUTION Off PATIENTS AND OPERATIVE MORTALITY. Age Group

O perative Deaths

Percentage In cidence.

171 ( 5 1 .8 $ )

8

4 .6

40 - 49

8 6 (2 6 .1 % )

5

5.8

50 and o v e r

73 (2 2 .1 % )

11

15.0

O peration s

U n d e r 40

330

24

Under t h e age o f f i f t y y e a r s t h e m o r t a l i t y r a t e rem ains w ith in reasonable l i m i t s .

In p a t ie n t s over f i f t y ,

m o r t a l i t y mounts r a p i d l y .

It

530 p a t i e n t s o p e r a t e d up on ,

the

i s worthy o f n o t e t h a t o f t h e

4 8 . 2 p e r c e n t w e re 40 y e a r s and o v e r ,

2 2 . 1 p e r c e n t b e i n g 50 y e a r s and o v e r .

Moreover,

Table V

u n d e r l i n e s the n e c e s s i t y f o r g i v i n g age d i s t r i b u t i o n w it h m ortality rate.

W ithout the form er,

the l a t t e r

i s m eaningless

when c o m p a r i s o n s a r e t o be drawn and t h i s i s e s p e c i a l l y the g a str o -e n te r o s to m y /g a str e c to m y c o n tr o v e r s y .

so i n

G astrectom y in

p a t i e n t s o v e r 50 y e a r s o f a g e i s a f o r m i d a b l e p r o c e d u r e and i n many c a s e s h a s b e e n a v o i d e d . of gastrectom ies,

however,

In V i s i o n s

(1948) la r g e

series

24 p e r c e n t w e r e i n t h e 50 y e a r s and

o v e r a g e g r o u p w i t h an o p e r a t i v e m o r t a l i t y o f 6 . 1 p e r c e n t . G a s t r e c t o m y f o r h a e m a t e m e s i s wa s n o t i n c l u d e d i n h i s s e r i e s .

-

PART

27 -

III.

A. - ANALYSIS OF TIN3ATISEACTORY RESULTS. 1.

PATHOLOGY. The a s s e s s m e n t o f t h i s s e r i e s h a s b e e n m a i n l y c l i n i o a l .

The p r e c i s e p a t h o l o g y i n m o s t c a s e s i s , Even when a v a i l a b l e ,

therefore,

unknown.

r a d i o l o g i c a l and g a s t r o s c o p i c c o n f i r m a t i o n

i s n o t a l w a y s p o s s i b l e and t h e d i a g n o s i s m u st r e s t on c l i n i c a l grounds. cases.

How ev er,

a c c u r a t e i n f o r m a t i o n was a v a i l a b l e i n 33

T a b le V I .

TABLE V I . - SITE OF ULCERS IN 33 CASES - X-RAY DIAGNOSIS. NO. OF CASES.

LESION G astro-jejunal ulcer

21

A c tiv e duodenal u lc e r

11

A ctive g a s t r i c u lc e r ( o r ig i n a l l y D .U .)

1

Due t o t h e d i f f i c u l t y i n d i a g n o s i n g m a r g i n a l u l c e r a t i o n , t h e r e has been c o n s i d e r a b l e doubt a s to w hich i s

t h e more common -

r e - a c t i v a t i o n or p e r s is t e n c e o f a c t i v i t y o f the o r i g i n a l duodenal u l c e r or stomal u l c e r .

Cooper (1948)

p o in t s out th a t

many o f h i s p a t i e n t s a t o n e t i m e o r a n o t h e r had X - r a y f i n d i n g s s u g g e s t i v e o f r e - a c t i v a t i o n o f t h e o r i g i n a l d u o d e n a l u l c e r bu t when d e f i n i t e p r o o f wa s a v a i l a b l e a t

subsequent o p e r a tio n ,

m a j o r i t y w e r e f o u n d to h a v e m a r g i n a l u l c e r s . Chenoweth/

Holman and

the

-

28 -

C he no w e th ( 1 9 4 2 ) n o t e d t h a t when b l e e d i n g o c c u r s i n a p a t i e n t who h a s h ad a g a s t r o - e n t e r o s t o m y f o r a d u o d e n a l u l c e r ,

th e haemorrhage

in m o st c a s e s o r i g i n a t e s from a m a r g in a l u l c e r r a t h e r than from a p e r s i s t i n g o r r e c u r r e n t duodenal u l c e r . related

It

should,

therefore,

he

t h a t i n t h e c a s e s i n t h i s s e r i e s w h i c h came t o o p e r a t i o n ,

a s f a r a s c o u l d he d e t e c t e d , m a r g i n a l u l c e r was t h e c a u s e o f symptoms i n a l l e x c e p t

two c a s e s .

The two e x c e p t i o n s w e r e i n

p a t i e n t s i n whom t h e stoma had c l o s e d , rep lica,

of th e ir pre-op erative

reformed,

w ith recurrence,

symptoms.

in exact

When t h e sto ma w as

r a d i o l o g i c a l h e a lin g o f the duodenal u l c e r took p l a c e .

The o p e r a t i o n f i n d i n g s i n h o t h t h e s e c a s e s s u g g e s t e d t h a t m a r g i n a l u lceration stoma.

and r e s u l t a n t

f i h r o s i s had p r o d u c e d c l o s u r e o f t h e

One f u r t h e r c a s e i s o f i n t e r e s t i n t h i s c o n n e c t i o n i n

t h a t he s u f f e r e d p e r f o r a t i o n o f a s t o m a l u l c e r 5 y e a r s a f t e r g a s t r o - e n t e r o s t o m y and a p e r f o r a t i o n o f a d u o d e n a l u l c e r 5 y e a r s later.

A r e c e n t Barium Meal e x a m i n a t i o n r e v e a l s t h e stoma t o h e

in efficien t

and t h e p r e s e n c e o f an a c t i v e d u o d e n a l u l c e r .

w o u ld a p p e a r ,

therefore,

c i r c u i t i n g operation

that

It

symptoms w h i c h r e c u r a f t e r a s h o r t

a r e m o s t commonly due t o m a r g i n a l u l c e r and

t h a t th e o p e r a t i o n performed f o r duodenal u l c e r g e n e r a l l y a c h i e v e s i t s p u r p o s e , n a m e ly h e a l i n g o f t h e o r i g i n a l d u o d e n a l u l c e r w i t h a g r e a t hazard o f producing a secondary u l c e r a t th e

st o m a .

T his

w oul d a p p e a r t o he a p o i n t o f c o n s i d e r a b l e p r a c t i c a l i m p o r t a n c e when o p e r a t i v e m e a s u r e s a r e c o n t e m p l a t e d i n c o n t i n u e d h a e m a t e m e s i s i n p a t i e n t s who h a v e p r e v i o u s l y u n d e r g o n e g a s t r o - e n t e r o s t o m y . The/

- 29 The f i n d i n g s i n t h e p r e s e n t i n v e s t i g a t i o n a u th o r s m entioned, situ a ted at,

in d icate

or near,

and i n t h o s e o f t h e

th a t the l e s i o n

i s m o s t commonly

th e stoma.

B a r b e r and B o g a t k o ( 1 9 3 8 ) a d m i t t e d o f few f a i l u r e s ,

i n w h o s e han d3 t h e o p e r a t i o n

enquiring in to

the causes of f a i l u r e ,

a p p o r t i o n e d m o s t b la m e t o a d h e s i o n s b e t w e e n t h e a f f e r e n t and e ffe r e n t loops. cent.

S t o m a l u l c e r w as i n c r i m i n a t e d i n o n l y 2 p e r

The p r e s e n t a u t h o r i s o f

the o p in io n t h a t t h e s e

a d h e s i o n a r e m o s t commonly t h e r e s u l t o f i n f l a m m a t o r y r e a c t i o n around th e stom al u l c e r .

A d h e s i o n s due t o o t h e r c a u s e s s u c h

a s o p e r a t i v e traum a and t a l c m u st be e q u a l l y common i n gastrectom y. (1949)

Cannon and B l a k e ( 1 9 0 5 )

and , more r e c e n t l y , Kay

have s u g g e s te d t h a t a poor c l i n i c a l

c a s e s o f g a s t r o - e n t e r o s t o m y , where to g a s t r o - j e j u n a l u l c e r a t i o n ,

r e s u lt in c e r t a in

symptoms c a n n o t be a t t r i b u t e d

may be due t o f a i l u r e o f t h e

e m p t y i n g m e c h a n is m w h i c h i 3 c o n t r o l l e d b y t h e j e j u n u m .

The

form er w r i t e r s c la im e d t h a t i n g a s t r o - e n t e r o s t o m y c o n t r o l o f e m p t y i n g was m a i n t a i n e d b y r h y t h m i c c o n t r a c t i o n s and r i n g s o f co n strictio n

i n t h e je j u n u m w h i c h a l t e r n a t e l y l e t down and h o l d

back th e g a s t r i c c o n te n ts . i n g a s t r e c t o m y and when i t

T h i s c o n t r o l must a l s o be p r e s e n t fa ils,

the

symptomatology i s

that o f

"dumping" a syndrome w h i c h h a s b e e n i n s i g n i f i c a n t i n t h e p r e s e n t series.

I t w o u ld seem,

therefore,

that fa ilu r e s a fte r

g a s t r o - e n t e r o s t o m y a r e l a r g e l y due t o though/

secondary u lc e r a t io n

- 29a t h o u g h r a d i o l o g i c a l and g a s t r o s c o p i c

e x a m i n a t i o n may f a i l t o

reveal i t . Ho c a s e o f g a s t r o - j e j u n o c o l i c

f i s t u l a occurred in th e

p a tien ts traced. 2.

SYMPTOMATOLOGY. The main symptoms a r e shown i n T a b l e V I I . TABLE V I I . SYMPTOM.

PERCENTAGE' OP SERIES.

Ho . OP GASES.

Pain

91

38.5

Haemorrhage ( a l l )

29

12.3

8

3.3

Haemorrhage w i t h o u t

pain

(a.)

PAIH.

P a i n o f a l l d e g r e e s o f s e v e r i t y and p e r i o d i c i t y w a s t h e p r e d o m i n a n t symptom. severe

I t was o f u l c e r t y p e and e x c e p t i n more

c a s e s , w a s r e a d i l y r e l i e v e d by f o o d and a n t a c i d s .

o f t h e p a t i e n t s w e r e u n a b l e to d i f f e r e n t i a t e from t h e i r o r i g i n a l c o m p l a i n t . s i t e and d i s t r i b u t i o n .

t h e pain was l e s s

th a n t h e p r e - o p e r a t i v e p a i n ,

f e a t u r e p r e v i o u s l y n o ted by A lv a r e z (1 9 3 9 ) p a t i e n t s were g r a t e f u l . (b) G a stro -in testin a l/

t h e ir recurrence

O th ers a p p r e c i a t e d a change in

I n 45 p a t i e n t s ,

s e v e r e and l e s 3 i n t r a c t a b l e

Many

HAEMORRHAGE.

a

and f o r w h i c h t h e

-

30 -

G a s t r o - i n t e s t i n a l h a e m o r r h a g e occurred i n 29 c a s e s , h a e m a t e m e s i s and 3 i n whom m e l a e n a was s u f f i c i e n t co n stitu tio n a l upset.

to

26

cause

8 c a s e s had had no p a i n w h a t e v e r ,

though

t h e r e had b e e n p e r i o d s o f marked d i g e s t i v e u p s e t s u c h a s h e a r t ­ b u rn ,

flatu len ce,

waterbrash,

etc.

38 c a s e s had h a e m o r r h a g e

b e f o r e o p e r a t i o n and 12 o f t h o s e had f u r t h e r b l e e d i n g a f t e r operation,

26 b e i n g f r e e f r o m t h i s c o m p l i c a t i o n .

On t h e o t h e r

hand 17 p a t i e n t s who had no p r e - o p e r a t i v e h a e m o r r h a g e , had b leed in g a f t e r op eration . Two p a t i e n t s d i e d a s a r e s u l t o f h a e m a t e m e s i s . Many p a t i e n t s had more t h a n o n e e p i s o d e o f b l e e d i n g . Table V I I I . TABLE V I I I . E pisodes o f B le e d in g . No. o f Haemorrhages. No. o f P a t i e n t s .

1 17

(c)

2 4

3

4

5

5

2

1

PERFORATION.

There were 5 p e r f o r a t i o n s in 4 p a t i e n t s .

A l l were

m a r g i n a l u l c e r s e x c e p t i n t h e p a t i e n t m e n t i o n e d a b o v e who s u s t a i n e d b o t h d u o d e n a l and m a r g i n a l p e r f o r a t i o n s .

A l l were

s u c c e s s f u lly sutured. 3.

INCIDENCE 0 ? MAJOR COMPLICATIONS. T a b l e I X g i v e s t h e number o f m a j o r c o m p l i c a t i o n s -

p erforation /

- 31 p e r f o r a t i o n and h a e m o r r h a g e and e l e c t i v e o p e r a t i o n s f o r r e l i e f of

symptoms,

in

each fo llo w -u p year 1 -2 0 .

The t a b l e i s

c o m p i l e d o n l y f o r p a t i e n t s s u f f e r i n g from d u o d e n a l u l c e r and gastric u lcer.

P yloric

s t e n o s is i3 not inclu ded.

o n ly one p a t i e n t in th e p y l o r i c a severe

relap se,

Indeed

s t e n o s i s g r o u p was c l a s s e d a s

havin g su b s e q u e n tly undergone th r e e e l e c t i v e

o p e r a tio n s for r e l i e f t of exclu din g th ose ca ses i s

symptoms.

The main r e a s o n f o r

to a l l o w o f more f a i r c o m p a r i s o n w i t h

t h e f i g u r e s p r o d u c e d by I l l i n g w o r t h e t a l ( 1 9 4 6 )

in t h e i r

i n v e s t i g a t i o n in t o the p rogress a f t e r p erfo ra ted p e p tic u lc e r . TABUS I X . INCIDENCE OF MAJOR COMPLICATIONS AND ELECTIVE SECONDARY OPERATIONS AFTER GASTRO-ENTEROSTOMY. COMPARI SON WITH FIGURES OP ILLINGWORTH ET AL ( 1 9 4 6 ) . F-U Year

Cases Observ­ ed

P erforation .

Haemorrhage. (0 .8 )

E lective O peration.

1

211

0

(1 .7 )

0

2

204

0

(1 .4 )

2 (0 .9 8 )(1 .3 )

3 (l.4 7 )(3 .3 )

3

202

1 (0 .4 9 )(3 .4 )

2 (0 .9 8 )(1 .5 )

1 (0 .4 9 )(1 .8 )

4

200

1

3 (1 .5

1 (0 .5 0 )(0 .9 0 )

5

197

3 (0.0 1 ) (3 .4 )

8 (4 .0 4 )(0 .6 )

0

6

196

0

3 (1 .5 3 )

1 (0.51)

7

193

0

5 (3.59)

1 (0.51)

8

190

1 (0.53)

4 (3 .0 8 )

0

9

190

0

3 (1 .5 6 )

1 (0.53)

10

184

1 (0.54)

2 (1.08 )

0

(1 .5 )

)(1 .2 )

0

T a b l e IX c o n t i n u e d on n e x t p a g e .

(3 .7 )

(1 .8 )

32 -

TABLE I X . E-U Year

(con td .)

C ases Observ­ ed

P erforation .

H a e m or rh age.

E lective O neration.

11

179

0

3 (1.67)

0

12

165

0

4 (2.42)

1 (0 .6 0 )

13

149

0

0

2 (1.34)

14

140

0

1 (0.71)

0

15

11 8

0

1 (0.8 4)

1 (0 .8 4 )

16

102

0

1 (0.9 8 )

0

17

84

0

2 (2.38 )

1 (1 .1 9 )

18

63

0

0

0

19

48

0

0

0

20

36

0

0

0

The f i g u r e s i n T a b l e IX r e f e r n o t t h e p a t i e n t s i n v o l v e d bu t t h e number o f i n c i d e n t s p e r f o l l o w - u p y e a r . Table VIII

As shown i n

s e v e r a l p a t i e n t s had more tha n one h a e m o r r h a g e .

Some 1 1 . 5 p e r c e n t o f p a t i e n t s s u f f e r e d a m a j o r c o m p l i c a t i o n , in c lu d in g e l e c t i v e o p e r a tio n w ith in 5 y e a r s o f undergoing a gastro-enterostom y.

1 .5 per cent p erfo ra ted ,

7.5 per cent

s u f f e r e d h a e m or r ha ge and 2 . 5 p e r c e n t s o u g h t r e l i e f f o r t h e i r symptoms by f u r t h e r o p e r a t i o n .

Comparable f i g u r e s from t h e

in v e s t ig a t i o n in to the progress a f t e r p erfo r a tio n o f p e p tic u l c e r b y I l l i n g w o r t h e t a l ( 1 9 46) a r e shown i n r e d .

W ithin

5 y e a r s o f u n d e r g o i n g o p e r a t i o n f o r p e r f o r a t i o n 20 p e r c e n t suffered/

-

33 -

su ffe r e d a major co m p lic a tio n ,

8 . 4 p er c en t having p e r fo r a te d ,

5 . 4 p e r c e n t h a v i n g h i e d and 9 . 4 p e r c e n t h a v i n g u n d e r g o n e e lectiv e

operation.

I t would seem,

therefore,

enterostom y has a c o n s id e r a b le e f f e c t ,

that g a str o ­

reducing th e in c id e n c e

o f m a j o r c o m p l i c a t i o n s i n p e p t i c u l c e r a t i o n by a b o u t 10 p e r c e n t . B. 1.

-

FACTORS iyjLUMOITTG RESULTS.

SI TE OF ULCER. For the purpose o f t h i s stu d y c a s e s w i t h combined g a s t r i c

(i.e .

l e s s e r curve)

g a stric u lcers.

and d u o d e n a l u l c e r s h ave be en g r o u p e d w i t h

P y l o r i c u l c e r s h a v e been g r o u p e d t h r o u g h o u t

w ith duodenal u l c e r s . ra te in duodenal u l c e r s ,

As f o r t h e t o t a l

For b r e v i t y ,

15 and 20 y e a r s o n l y a r e shown.

f o r D .U ., TABLE X . /

s te n o s is has

T a b l e s X, XI and XII

r e l a p s e r a t e s and t h e i n c i d e n c e o f s e v e r e , m o d e r a t e

and m i l d r e c u r r e n c e s . 10,

the r e la p s e

g a s t r i c u l c e r s and p y l o r i c

been c a lc u la t e d f o r each fo llo w -u p year. show t o t a l

series,

G.U. and p y l o r i c

f i g u r e s f o r 1, The t o t a l

2,

3,

4,

relapse rat4e

s t e n o s i s are graphed i n F i g . I I .

5,

TABLE X .

-

PaOPSHAL ULCER.

INCIDENCE OE SEVERE. MODERATE. MILD ABB TOTAL RELAPSES. R elapses, Moderate

Total R elaoses.

3MJ. Year

C ases Observed

1

186

1 3 (6 .9 9 )

1(0.53)

1(0.53)

1 5( 8 . 0 5 )

2

181

2 6(14.36)

4( 2 . 2 1 )

4(2.21)

34( 1 8 . 7 8 )

3

180

36(20.0 )

7( 3 . 8 9 )

1 1(6.11)

54 (3 0 .0

4

179

37(20.67)

7( 3 . 9 1 )

1 3(7.26)

57(31.84)

5

179

40(22.34)

8(4 .4 6 )

15(8.39)

63(35.19)

10

169

46( 2 7 . 2 1 )

12( 7 . 1 0 )

17(10.06)

75(44.37)

15

1 07

30(28.03)

8(7.48)

10(9.35)

48(44.86)

20

32

8(25.0 )

TABLE X I . /

Severe

6(18.75)

Mild

6(18.75)

20(62.5

)

)

TABLE

XL.

35 -

-

GASTRIC ULCER.

INCIDENCE Off SEVERE. MODERATE. MILD AND TOTAL RELAPSES. R elapses. Moderate

F-U. Y e ar

Cases Observed

Severe

1

25

8( 3 2 . 0

2

23

6( 2 6 . 0 9 )

3

22

4

)

0(0)

10 (4 0 .0 )

3(13.04)

3(13.04)

12(52.17)

5( 2 2 . 7 2 )

3(13.64)

3(13.64)

11 (5 0 .0 )

21

5( 2 3 . 8 2 )

3(14.28)

2(9 .5 2

)

10( 4 7 . 6 2 )

5

18

3( 1 6 . 6 6 )

3(16.16)

2(11.11)

8(44.44)

10

15

2(13.33)

3 (2 0 .0

)

2(13.33)

7(46.66)

15

11

2(18.18)

2(18.18)

2(18.18)

6(54.54)

20

4

1 (25.0

0(0)

1 (2 5 .0

2(50.0

TABLE X I I .

)

-

2(

To t a l R elaoses.

ii'iid

8 .0 )

)

)

PYLORIC STENOSIS.

INCIDENCE OP SEVERE. MODERATE. MILD AND TOTAL RELAPSES. R elapses. M o d e ra t e

F-U. Year

Cases Observed

1

25

0(0)

2

25

1 (4 .0

)

2 (8 .0

)

3(12.0

3

25

1 (4 .0

)

2 (8 .0

)

3 (1 2 .0 )

6(24.0

4

25

1 (4 .0 )

2(8.0

)

3 (1 2 .0 )

6(24.0 )

5

24

1 (4.16)

3(12.5)

3(12.5

)

7 (2 9.16)

10

22

1(4.55)

3(13.63)

3(13.63)

7(31.81)

15

13

0(0)

2(15.38)

1(7.69

)

3(23.07)

20

4

0(0)

0(0)

1 (25.0 )

1 (2 5 .0 )

Severe

0(0)

To t a l R elapses.

M ild o(o)

0(0) )

6(24.0 ) J

Fig. 2.

Comparison

of

Follow

and

36

"Year$

of

in Puodenai Ulcer, Gas trie Ulo ©r

S>ten.o5i,S.

relapses

Pyloric

total

-

-

The r e s u l t s gastric

37 -

show a h e a v y i n c i d e n c e o f r e l a p s e s i n b o t h

and d u o d e n a l u l c e r g r o u p s .

In the duodenal group,

t h e r e l a p s e s mount r a p i d l y t o 3 5 p e r c e n t i n 5 y e a r s .

In the

s u b s e q u e n t 15 y e a r s ,

a f h r t h e r 27 p e r c e n t r e l a p s e .

g a s t r ic u lc e r group,

t h e s e r e l a p s e s i n c l u d e 6 c a s e s o f carcinoma

o f stomach, years.

e x p la in in g the la rg e f a i l u r e

In th e

r a t e in th e f i r s t few

I n t h e g r o u p w i t h o b s t r u c t i v e symptoms, t h o u g h

considerab ly b e tte r , However,

th e r ela p se rate i s

su r p r isin g ly h igh .

a l l b u t one o f th e r e l a p s e s were o f moderate o r m ild

s e v e r i t y i n c o n t r a s t t o t h e d u o d e n a l and g a s t r i c u l c e r g r o u p s . Even s o ,

th is

r e l a p s e r a t e i s much i n e x c e s s o f t h a t g e n e r a l l y

expected. 2.

SEX. The r e s u l t s a c c o r d i n g t o

and XIV.

s e x are l i s t e d in T a b le s XIII

The t o t a l r e l a p s e r a t e s f o r m a l e s and f e m a l e s ,

the r e s p e c t iv e in c id e n c e o f severe r e la p s e s i s TABLE X I I I . /

and

shown i n E i g . I I I .

-

38 -

TABLE X I I I .

-

FEMALES.

INCIDENCE OF SEVERE. MODERATE. MILD AND TOTAL RELAPSES. R elapses.

Total R elaoses.

F-U. Yea r

Cases Observed

1

36

0(0)

1(2.77)

0(0)

2

35

1 (2 .8 6 )

5(14.28)

3(8 .5 7

)

9(25.71)

3

35

1 (2 .8 6)

5(14.28)

5(14.28)

1 1(31.42)

4

35

1 (2 .8 6)

5(14.28)

6(17.14)

12(34.28)

5

35

1(2 .8 6 )

5(14.28)

6(17.14)

12(34.28)

10

33

1(3 .0 3 )

5(15.15)

6 (18.18)

12( 3 6 . 36)

15

24

1(4 .1 7 )

4 (16.66)

5 (20.83)

1 0(41.66)

20

7

1 (1 4 .2 8 )

1(14.28)

2( 2 8 . 5 7 )

4(57.13)

Severe

Moderate

TABLE X IV .

.

M ild

1 (2.77 )

h a les.

INCIDENCE OF SEVERE. MODERATE. MILD AND TOTAL RELAPSES. R elapses

F-U. Yea r

Cases Observed

Severe

1

200

2 1 (1 0 .5

2

19 3

32( 1 6 . 5 8 )

3

19 3

4

M o d e ra t e

T o ta l R elapses.

M il d )

24(12.0 )

5( 2 . 5 9 )

6(3.10)

43(22.27)

40(20.72)

8(4.14)

11(5.70)

59(30.56)

189

39( 2 0 . 6 3 )

8 (4.23)

13(6.87)

60(31.73)

5

186

42(22.58)

10(5.37)

1 4 ( 7.53)

66(35.48)

10

17 3

47( 2 7 . 1 6 )

13(7.51)

17(9.82)

77(44.49)

15

10 7

32( 2 9 . 9 1 )

8 (7.47)

8( 7 . 4 7 )

48(44.85)

20

33

9( 2 7 . 2 7 )

6(18.18)

6(18.18)

2l( 63.63)

)

2(1.0

)

1 (0.5

Tr’ig 3.

Compansorz

of* 'Tota-J and

tSevere- irelajo^e^

in_ .Msilosf a.ixL t remaJl05' -

-

*

39 -

a prt0pr.*oTii a S ^ i r ^ c x r a ^ , o

£ * o

-

40 -

The t o t a l r e l a p s e r a t e f o r m a l e and f e m a l e i s

rem arkably

s i m i l a r but in q u ir y i n t o th e ty p e o f r e l a p s e r e v e a l s th a t in fem ales,

the

c la sse d as

r e c u r r e n c e s a r e much l e s s s e v e r e .

a severe relap se,

The o n e f e m a l e ,

s u f f e r e d from m a r g in a l u l c e r a t i o n

b o t h a f t e r g a s t r o - e n t e r o s t o m y and g a s t r e c t o m y . It

is

seen,

therefore,

women a r e much s u p e r i o r t o

t h a t t h e r e s u l t s t o be e x p e c t e d i n

t h o s e i n men.

n o t e d t h a t o f t h e 35 f e m a l e s i n t h e p y lo ric

stenosis,

sh o u ld a l s o be

13 w e r e c a s e s o f

2 h ad a p r e v i o u s h i s t o r y o f p e r f o r a t i o n and 3

o f haem atem esis o f duodenal o r i g i n . un com plicated p e p tic u l c e r s , 3.

series,

It

The r e m a i n i n g 18 w e r e

2 g a s t r i c a n d 16 d u o d e n a l .

AGE AT OPERATION . The r e s u l t s a c c o r d i n g t o a g e a t t h e t i m e o f o p e r a t i o n a r e

shown i n T a b l e s XIV, XV, XVI, XVII and t h e t o t a l in each age group a re TABLB XV. /

shown i n F i g . I V .

relap se r a te s

41 TABLE X V .

-

PA T IE N T S UNDER 3 0 .

THE LHCIDSHCE OF SEVERE, MODERATE, MILD AND TOTAL RELAPSES PER FOLLOW-UP YEAR. R elapses.

T otal R elaoses.

F-U. Tear

T otal Observed

Severe

1

44

7 (1 5 .9

)

0(0)

0(0)

2

44

1 1 (2 5 .0

)

2 (4 .5 4 )

2(4 .5 4 )

15(34.08)

3

44

16( 3 6 . 3 6 )

3( 6 . 8 2 )

2 1(47.72)

4

44

16(36.36)

2(4 .5 4 )

4(9.10)

2 2 (5 0 .0

5

44

18(40.90)

2( 4 . 5 4 )

4 (9.10)

2 4(54.54)

10

43

21(48.83)

3 (6 .9 7 )

4(9.36)

2 8(65.16)

15

27

12(44.44)

2(7.41)

4(14.81)

18(66.66)

20

12

4( 3 3 . 3 3 )

2(16.66)

2( 1 6 . 6 6 )

8 ( 66.66)

Moderate

M ild

7(15.9

to•

I''ITif

TABLE XV I .

■M M M M M M T9

-

PATIESTTS -m !■39 YEARS. — —■— M III ■30 H1 If m I l '^ a — WWW—

THE INCIDENCE OF SEVERE, MODERATE, MILD AND TOTAL RELAPSES _________________________ PER FOLLOW-UP YEAR._________ Relap ses Moderate

F-U. Year

Cases Observed

Severe

1

81

6 (7 .4 2 )

1(1 .2 3 )

2(2 .4 6 )

9 (11.11)

2

79

1 4(17.73)

3( 3 . 7 9 )

2(2.53)

1 9(24.05)

3

77

1 4 (1 8.19)

4 ( 5.19)

5 (6.49)

23(29.87)

4

77

15 (1 9.48)

4(5 .1 9 )

5 (6 .4 9 )

3l( 31.16)

5

77

15(19.48)

4 (5 .1 9 )

7(9.09)

26( 3 3 . 7 6 )

10

75

18(24.0

6 (8 .0

)

1 0(13.33)

34(45.33)

15

46

1 4 (3 0.43)

4 (8.69)

5(10.88)

23 (5 0 .0

20

17

* 5(29.41)

2(11.76)

5( 2 9 . 4 1 )

12(70.58)

)

M ild

T otal R elaosei

)

)

)

TABLE X V I I .

-

PATIENTS 4 0 -

49 YEARS.

THE INCIDENCE OF SEVERE, MODERATE, MILD AND TOTAL RELAPSES PER FOLLOW-UP YEAR. F-U. Year

Cases Observed

1

60

0(0)

2

60

2 (3 .3 3

3

59

4

Relap s e s . Mo d e r a t e

Severe

M ild

T otal R elaoses.

1 (1 .6 6 )

0(0)

1(1.66)

)

1(1 .6 6 )

2 (3 .3 3 )

5 (8 .3 3 )

3 (5.08

)

2(3 .3 9 )

5(8 .4 7 )

10(16.94)

59

4 (5.78

)

2( 3 . 3 9 )

5(8.47)

1 1(18.64)

5

58

6 (10.34)

3 (5.17)

5(8.62)

14 ( 2 4 . 1 3 )

10

54

7(12.96)

3 (5.55)

5(9.26)

15(27.77)

15

35

5(14.28)

3(8 .5 7 )

3 (8.57)

11( 3 1 . 4 2 )

20

8

0(0)

2 (2 5 .0 )

1 (12.5)

3 (37.5 )

TABLE X V I I I .

-

PATIENTS OVER 5 0 .

THE INCIDENCE OF SEVERS, MODERATE, MILD AND TOTAL RELAPSES PER FOLLOW-UP YEAR. F-U. Year

Cases Observed

Severe

R elap s e s . Moderate

1

51

8 (1 5 .6 8 )

3 (5.88

2

46

7(15.22)

3

46

4

)

M ild

T otal R elaoses.

1(1.96)

12(23.52)

4(8 .6 9 )

3 (6.52)

1 4 (30.43)

8 (1 7 .3 9 )

5(10.87)

4(9.69)

1 7(36.95)

44

6 (13.63)

5(11.37)

4( 9 . 6 9 )

15( 3 4 . 0 9 )

5

42

5(11.90)

5(11.90)

4(9.53)

14 ( 3 3 . 3 3 )

10

35

3 (8 .5 7 )

5(14.28)

4 (11.43)

12( 3 4 . 2 8 )

15

24

2(8.33)

3(12.50)

1(4.17)

6(25.00)

20

3

0(0)

2( 6 6 . 6 6 )

0(0)

2(66.66)

43 e------- 10C>XXsrpi-^Xlt S>3 -

§ 0

M Qj PU 0

0

+J -U

S (5 (D

2P H

«

0 (P cu 50

E $ S’ d

f 00 Hi •rl

s-j-

-

The f i n d i n g s

.44 -

show i m p r o v e s e n t i n t h e

in c r ea sin g age of th e p a t ie n t. heavy in c id e n c e in th e f i r s t Carcinoma o f Stomach. relap ses i s

r e s u lt s w ith the

I n t h e o v e r 50 a g e g r o u p ,

5 years is

the

due t o 5 c a s e s o f

The i n c i d e n c e o f m i l d and m o d e r a t e

rem arkably c o n s t a n t in a l l

w i t h a g e "being i n t h e l e s s e n i n g

decades,

t h e im p r o v e m e n t

in cid en ce o f severe r ela p se s.

F u r t h e r f a c t o r s l e n d i n g t h e m s e l v e s t o im p r o v e m e n t i n r e s u l t s w i t h age a r e t h e d i s t r i b u t i o n s o f t h e c a s e s o f p y l o r i c the

fem ales.

O f t h e f o r m e r 25 p a t i e n t s ,

s t e n o s i s and o f

12 and 10 a r e f o u n d i n

th e 40-49

and o v e r 50 y e a r s r e s p e c t i v e l y .

Of t h e 36 f e m a l e

p atien ts,

1 3 and 11 a r e f o u n d i n t h e 4 0 - 4 9 and o v e r 50 g r o u p s

resp ectiv ely . 4.

DURATION OF THE PEB-QPSRATIVF ULCER HISTORY. The d u r a t i o n h a s b e e n g r o u p e d i n 5 y e a r p e r i o d s .

X V I I I , XIX, XX and XXI. F ig.

T ables

The t o t a l r e l a p s e r a t e s a r e shown i n

V. *

TABLB XIX. /

- 45 TABLE XIX.

-

PRE-OPERATIVE HISTORY

-■ 1 - 4

YEARS.

INCIDENCE OF SEVERE. MODERATE. MILD AETD TOTAL RELAPSES. R elapses. M oderate

F-U . Year

Cages Observed

1

66

8 (1 2 .1 2 )

1(1 .5 1 )

0(0)

2

63

11(17.46)

2 (3 .1 7 )

1 ( 1.59)

14(22.22)

-3

62

14(22.58)

3(4.84)

5 (8.06)

22(35.48)

4

62

15(24.19)

3 (4.84)

5 (8 .0 6 )

23( 3 7 . 0 9 )

5

61

1 6 (2 6 .2 5 )

3 (4.91)

5 (8 .2 0 )

24( 3 9 . 3 4 )

10

53

16( 3 0 . 1 9 )

2( 3 . 7 7 )

3 (9 .4 3 )

23(43.39)

15

35

1 3(37.14)

2 (5.71)

3(8.57)

18(51.42)

20

15

5( 3 3 . 3 3 )

2(13.33)

3 (2 0 .0 )

10( 6 6 . 6 6 )

Severe

-

TABLE XX.

PRE-OPERATIVE HI 3T0HY

M ild

-■

5 - 9

T otal R elaoses. 9 (1 3 .6 3 )

YEARS.

INCIDENCE OF SEVERS. MODERATE. MILD— AM D TOTAL RELAPSES. > £ aS o 13 f t

£ O •rl p

P

£

05 *» •H P

i— i

O

•

OS a)

•

ft P

>1 £ Ho 05 ft 13 -p S £ O o u o a> » £

d O 13 H P f t a5 p Jh

p ;£ aS P Jh o> a) ft £ o o Jh 13 © © P

u a> © p

•rH f t

•H f t

ft d

>> 6 o p o © Jh P CO

© to aS o> P ft

Tl« 0) ft

£ O O , u

•

13 rH © a5 p £ © f t -H qO ®

Jh Jh aS ©

>> s o p o

p

©^ cS o> P ft

a> 53 o Pi 03 3 O J

© o rH 3

3

© Jh P ^

Jh © H ft © O f t © ft £ h Jh - P 3 f t f t o! Eh f t Jh o ® ® < H ,a f t 13 P aS © £ g £ ft H • © O Jh •h

Jh

ft d

£

O

13 I H *H flS JH d P

13 £

£ © © g o! ©g qOO Jh p d 33 ft £ ft ft

O

Jh f t

o! P

• 1-1

cS ©

©

P

^

ft

£ ft o ©

Jh >>

ft

O

£ •H

Jh

© © g! • ft f t

o ft

p £

£© H

* £

o o o

P © d ©

ft

to >> o> s H o

Eh O

ft

>> s o p o

©

g Jh o ft

-p CO o

©

O P

^

^>> d

o>

ft © to ft f t iiJ f t

• £

© O P © Jh © § §

ft ©

p

•a

o

22

aS

© o

CO bOft 05 00 ft o 1

Jh

Jh • ft fft ft* o> O ft

p

00

cSj

ft

© •sf d o>

•

£

£ a?

•H

£ •rH

ft

ft

• Jh tfl © JH O

aJ h

^

£ •H 05

d

ft

£

c *d •H g d o

o

£

•H 05

ft >

ft

© • Jh

• Jh

©

ta ©

m

Jh O d ft

Jh o

o3 f t E>

^

D

>

13 d

©

• Jh bO © Jh o cS f t a e >

•Pp o o

ft

to

•H • g © O

• -P H

•

d © u o o 05 © £ a> ft © >»

ft

02

•

•

o

ra

rt 0? £

ft 00

O

•H £ •H CO £ -rt

m ra -h «

E>•

tD•

ft

ft

f t• ft

O P

£ o 0) ■rt Pi -p

1 Jh

•o > « ft ft ft

c Cl

a

K 0) cn • o

•

•

•as O £ ft © >»P

f t•

f t•

ft

ft

o> o>

to to o>

Ph W

to

CM

CM

ft

rl

CO o>

H

ft

ft

m

m

a

Ph

a

a

H

CM

to

to

to

rH

to o> ft

to to o>

rH

a>

U

bD0) oj ft {3 Jh O

«H o

1 £ Jh

e £ o XJ

p

1 0

ft

ft

©

£

o £ •H o P u •H 05 £ P o CM05 •H Jh 1 3 Jh © £ o ft M o

4)

Jh O

©

O © © *d ©-— l> OS r> cv■rl s - x -P P ra cO o 'p a cr> eg P rH cS o p >>

© ©

t>

s © . Pi eg ra a -s a

H

3

10

©

•H

COtD £> rH • •

a

. O r t -P

J 4 r l P, o -h a d -p >» g to ra

JH

rt

ao p

Pi

© eg .

P ip

a © (30 Jh X)

£

S -H eg I

CO

CO

•

© ,P XJ P

Jh ©

£

-P

•P ra

Jh

o

o «H

P

a

p Pi

-p

ra Jh *rH © ra

o J2


x$\ • ■d ra ©

ap o to

p -rH

a

a Jh

H ©

o

Eh O

Pi

©

Jh ©

O H

P

©

Vl

p p © • O p © p

•

a 'p >> ©

ra

Jh

P

Pi ra

eg eg Ph Xi

>> © CO P i

rH

*o ©

a o

&§

o

eg r t

P aS

o © JH

o

P

•d p

Jh

to

ra eS

• 03 rH

P •rH O P X } •rl eg P P O CM eg

© (30

b |Jh ©

Jh Jh © P o Pi M CH O

O© d ©

Jh JH Jh O

3 a

Pi Jh

(30 ©

rt O

Q P «p o

i

a

cS © eg Ph Jh X l

eg Ph

g3 © . g ra

« Jh

Cg to

Jh

p

o ©

'O

i to (30 *H

u

© Jh Jh Jh Jh O

• Jh

* eto ©

Jh o eg rH a JP

*p o o

p

p

O ^

CM

to

• P rl CO o

Jh O • CtS rH

P

•H P

* Jh x) ?Jh °tO O© r©t

P CJ> r t r t © rH P -H

P

Jh P 03 ra i j i eg CO P rH

ra o o fit ra ra P O rH •H rH P eg

pi © Pt raa i— • Jh

530 © Jh O Cg rt

T3 ^ P Jh eg Jh

o

p a

•rl © © eg

Pi

(30

1^1 P

to

•rl © t—1 >

1

©

•d eg © a (uo O Jh p eg CO rH

P &

Jh Jh

o

a

p •H © eg a PH

• Jh

to

©

Jh O eg rH tP

P •H eg Pi

• Jh

CiO© Jh o .eg r t

S

'm t»

to

rH

-p

3 © Jh © O O eg to © P © C © >> o

to H

m rH «H

•

a to

p o •H £j fctO (30 •h aj

tP ♦

£p

ft

p

l> to o»

to

rH

CM

to

iP P

tP

P

•

*p «

!p

Q

p

P

tO

O

•

♦

Jh r t

xs

O ft

p o o

Jh

P

• p o

© r t P lP

O os

rH

o*

CM

CM

o>

o>

o>

CO

a rt

rt rt

tO

o>

o>

CM

to

rH

X

©

to CO

CO o>

P rH

© tt£> ivt

• Jh

(30© Jh o eg rH

rt

o © •H H P © eg to

© bo n»

rH

©

o

O CO

I © O rt &

P

Vi tO

>> a o p o

©

2

eg c 0* © © tit eg r t ^ ©

© (30

p o

P

ra «d to t3 o

p£| O

o

O -H O Jh Xi © rt tO tiQ P P

• CM

ra ^ eg o> tb H

o © © Pi

33 O

p to X3

I rH

© Jh

P

o P p ©

CO

p p

© Jh

a

tO

a © o xi

rt

p

eg I

tO

>> £

>>

page

,Q

. •

rt

next

i

©

«

on

•P

XS

p

53 -

Contd.

-

-

54 -

ra

atj

p -h P i ra

a

^ £» ra co p,

a

ra gPi >

p P o

c8 H

O P

P c8

P

c8

xi p O

t4

O