The surgery of the stomach
From Primary Surgery
Contents |
Peptic ulcer
The surgery you can do on a patient's stomach or duodenum is limited to: (1) Treating his peptic ulcer if it perforates. (2) Doing a gastroenterostomy or pyloroplasty if his pylorus stenoses. (3) Treating him if his ulcer bleeds. (4) Perhaps doing an elective truncal vagotomy and gastroenterostomy if he has a chronic dis- abling duodenal ulcer which has resisted medical treatment. Duodenal ulcers are a common cause of epigastric pain in most parts of the world. You will need to take a careful history to dia- gnose and manage them. This can be difficult in a villager, so enquire how the patients in your community express their ulcer symptoms. They are unlikely to give you a clear history that their pain is relieved by food, or by antacids, for example, and their physical signs may be minimal. So, in spite of the limit- ations of the history, it is likely to be the only way you have of making the diagnosis. When a patient presents with the surgical complications of peptic ulcer disease, you may have to enquire carefully to find out that he has had any previous ulcer symp- toms. In India, antacids may be as expensive as cimetidine from a cheap secondary source. The decision to abandon medical for surgical treatment will often depend on how poor he is. If he is rich, he can afford surgery, or cimetidine and antacids; if he is poor, these drugs may cost more than his salary, so you may have to operate. Peptic ulcers, in India in particular, behave dif- ferently from those in the West. Operate early, and don't wait to be pressed to do so by the patient. PEPTIC ULCER DISEASE HISTORY. Has the patient had heartburn, dyspepsia, or epigastric pain? If, so, how long for, and has it recently got worse? Does it have the features of peptic ulcer pain -- epigastric, dull, boring, worse at night and when his stomach is empty; relieved by food, milk, antacids, vomiting, and belching; and aggravated by coffee, alcohol, and smoking? The periodicity of the symptoms is im- portant at first. Has he any reason for stress, in his family or at work? Has he been drinking? Weight loss? Black stools? EXAMINATION. Tenderness in his epigastrium will be his only physical sign? MEDICAL TREATMENT. No smoking, no spices, and frequent small meals help his symptoms. Four weeks treatment with cimeti-dine 200 mg three times daily, with 400 mg at night will cure 70% of cases temporarily. If this can be followed by 400 mg at night, there will be less chance of recurrence.
Perforated gastric or duodenal ulcer
Classically, when a patient's peptic ulcer perforates, it floods his peritoneum with the acid contents of his stomach, and gives him a sudden agonizing pain. He may be able to tell you the moment the pain began; it is constant, it spreads across his entire upper abdomen and later all over, and is made worse by deep breathing or movement. Usually, he lies still in excruciating pain, and breathes shallowly without moving his abdomen. Occasionally, he writhes about in agony. He is pale, sweating, and hypo- tensive, with a fast pulse (usually), a normal temperature, and a stomach which is not distended. Typically, his abdomen has a board-like rigidity, unlike that in any other disease, which may be so complete that you cannot elicit tenderness, except when you examine him rectally. After 3 to 6 hours his pain and rigidity lessen, he feels better and a 'silent interval' begins. Then, at about 6 hours, signs of diffuse peritonitis develop, accompanied by abdominal distension and absent bowel sounds. There are difficulties: (1) So many patients have dyspepsia, that a previous dyspeptic history is not much help. (2) You may have difficulty in distinguishing the exacerbation of a peptic ulcer from a subacute perforation (a small sealed leak) -- so rememb- er this possibility and watch him carefully. (3) Fluid may track down his right paracolic gutter and cause pain and tenderness in his right iliac fossa, simulating appendicitis. (4) If he perforates in bed while he is suffering from something else, which is not uncommon, the dramatic onset may be absent. Instead, he may merely 'take a turn for the worse', his pulse rate rises, and you find that he has upper abdominal guarding. If he has perforated, he needs an urgent laparotomy. If he is fit, and you operate within 8 hours, the result will be good. If you delay 12 hours, his chances of survival fall greatly. If you can suture his perforation, he has a 50% chance of having no more symptoms, and a 25% chance of having dyspepsia which will not be severe enough to need major surgery. Although the standard treatment is an urgent laparotomy, to close the hole in his duodenum or stomach, and to wash out his peritoneal cavity, there are some indications for treating him non-operatively, as described below. This is less demanding
technically, but it needs more time, and you will need good judgement to know: (1) When you have made a wrong diagnosis, and (2) when non-operative treatment is failing, so that you need to operate. The rule in all emergency surgery is to do only what is neces- sary. Closing the perforation is not difficult, but be sure to wash out his peritoneum when it has been contaminated . For this you will need plenty of warm saline.
PERFORATED PEPTIC ULCER
DIFFERENTIAL DIAGNOSIS. The main diagnostic difficulty is appendicitis, which is important because it needs a different inci- sion. Find out the relative frequency of these two diseases in your community. Suggesting perforation -- referred shoulder pain, usually on the patient's right, the absence of fever -- this develops late in a per- forations -- hock (when generalized rigidity is the result of appen- dicitis, he is not usually shocked), and a litre or more of stomach aspirate. Suggesting appendicitis (12.1) -- a colicky onset, fever, a small stomach aspirate of mucoid or bile-stained fluid. X-RAYS. If the diagnosis is clear, these are unnecessary and un- kind. If you take them, give him some intravenous morphine and aspirate his stomach first. Take an erect AP chest film. Make sure he is upright and the tube is horizontal. Look for a thin linear gas shadow between his diaphragm and his liver or stomach. If he cannot sit or stand, take a lateral decubitus film and look for air under his anterior abdominal wall. If his ulcer has perforated into his lesser sac, you may see a large irregular gas shadow in the centre of his upper abdomen, with an outline which is different from that of a loop of gut. CAUTION! (1) An ulcer can perforate almost silently in the very old, or in the course of another disease. (2) The absence of gas does not exclude the presence of a perforated ulcer. (3) Gas can also come from a ruptured diverticulum or an appendix (un- common). NON-OPERATIVE TREATMENT FOR A PERFORATED PEPTIC ULCER INDICATIONS. (1) A perforation which appears to have sealed it- self already, as shown by diminished pain and improved abdomi- nal signs. (2) Heart or lung disease, which increases the surgical and anaesthetic risks. (3) The patient who is admitted after a day or two and is almost moribund with diffuse peritonitis. Non-opera- tive treatment may be best, because it is unlikely that he would have survived so long with an open perforation. CONTRAINDICATIONS. (1) An uncertain diagnosis. (2) The ab- sence of really good nursing by day and night. (3) The seriously ill patient, with a short history, whose only hope is vigorous resusci- tation and an urgent laparotomy. If you do decide that such a patient is 'not fit for surgery', wait to do so until vigorous resusci- tation has failed -- don't make the decision when he is first admitted. METHOD. Give him morphine 5 to 10 mg intravenously. As soon as this has had time to act, pass a large tube and empty his sto- mach. When it is empty, pass as wide a radio-opaque nasogastric tube as he will tolerate. Take him to the X-ray department and take AP erect films of his chest and lower abdomen. These should show that there are no fluid levels in his stomach, and that the tube is well placed. If not, adjust it and take more films. Look for subdiaphragmatic gas to confirm the diagnosis. Back in the ward, ask a nurse to aspirate his stomach every 15 minutes initially. Set up an intravenous drip, and monitor his pulse and blood pressure hourly. He is progressing well if: (1) His pain eases, so that he does not need more analgesics, and (2) another erect film 12 hours later (optional) shows no fluid level, and no increase in the gas under his diaphragm. Continue to 'suck and drip him' for 4 or 5 days, until his abdomen is no longer tender and rigid, and his bowel sounds return. If pain persists, or the gas under his diaphragm increases, operate. LAPAROTOMY FOR A PERFORATED PEPTIC ULCER EQUIPMENT. A general set. Several litres of warm saline. Two assistants make upper abdominal surgery easier. PREPARATION. Pass a nasogastric tube and aspirate his sto- mach (4.9). He will have lost much fluid into his peritoneal cavity, so correct at least part of his fluid loss before you operate, as in Section A 15.3. If he is dehydrated or hypotensive, give him 1 to 3 litres of fluid rapidly. If more than 12 hours have elapsed since he perforated, he will need even more. Operate soon, but not before you have resuscitated him. He has not bled, so he does not need blood. PERIOPERATIVE ANTIBIOTICS. (2.9) are only indicated in late cases with peritonitis. ANAESTHESIA. (1) General anaesthesia with good relaxation. (2) If this is contraindicated because of lung disease, do an inter- costal block (A 6.7), from T6 to T11. Premedicate him with intravenous morphine, and palpate his ab- domen when this has taken effect. If his rigidity is generalized, morphine will make little difference if he has a perforation, but if he has appendicitis, rigidity will now be localized to his right iliac fossa. INCISION. Make a midline or upper right paramedian incision (9.2). The escape of gas as you incise his peritoneum confirms the diagnosis. Initial examination will probably show a pool of exudate under his liver, with food and fluid everywhere, and an inflamed peritoneum. The fluid may be odourless and colourless with yellowish flecks, or bile-stained -- if it is pure bile, he has biliary peritonitis. If you see patches of fat necrosis, he has acute pancreatitis. If there is no fluid or little fluid, push a swab on a holder beside his ascend- ing colon towards his caecum. If you withdraw it soaked with fluid, this suggests a perforation. Draw his stomach and transverse colon downwards: you may see flecks of fibrin, and perhaps pieces of food. To expose his stomach and duodenum place a self-retaining retractor in the wound. Place a moist abdominal pack on the greater curva- ture of his stomach. Draw this downwards, and ask your assistant to hold it; at the same time ask him to hold the patient's liver up- wards with a deep retractor. Put an abdominal pack between the retractor and his liver to protect it. If neces-sary, get the help of a second assistant. Suck away any fluid, looking carefully to see where it is coming from. Search for a small (1 to 10 mm or more) circular hole on the anterior surface of his duodenum, looking as if it has just been drilled out. Feel it. The tissues around it will be oedematous, thickened, scarred, and friable. If his duodenum is normal, look at his stomach, especially its lesser curve. If the hole is small, there may be more to feel than to see. Sometimes, a gastric ulcer is sealed off by adhesions to the liver. Remember that a gastric ulcer may be malignant: consider biopsy. If his stomach is adherent to his liver, separate it. Open his lesser sac through his lesser omentum. Feel the post- erior surface of his stomach. An ulcer high up posteriorly may be difficult to find. Feel carefully. If his stomach and duodenum are normal, feel gently downwards towards his appendix. If there is a mass or it is obviously inflamed, close the midline incision and make a gridiron one. Two smaller incisions are better than one huge one. To close the perforation, use 2/0 chromic catgut on an atraumatic needle to bring its edges together with 1 to 3 deep stitches. If the tissue is so rigid that the stitches cut out, you may be able to re- duce the size of the hole with loose sutures, or by using a purse string suture. Always sew omentum over the perforation, by bringing up a fold of greater omentum. A hole so plugged is unlikely to leak. Wash out his peritoneal cavity. This is absolutely critical, and may be more important than closing the hole. Tip a litre of warm saline into his peritoneal cavity, spread it well, and then suck it out again. Repeat this several times, and try to wash out every possible re- cess in his upper abdomen. Mop the upper surface of his liver. Instil tetracycline 1 g in a litre of of saline and leave it in. This may be unnecessary if you operate within 6 hours of the perforation. FURTHER PROCEDURES. If: (1) his general condition is good, and you are operating early (within 6 to 8 hours of a duodenal, or particularly a gastric perforation), and (2) he has severe ulcer di- sease (uncontrollable symptoms, or a previous bleed or perfo- ration), and (3) you are experienced, consider doing a vagotomy and gastroenterostomy (11-4). Otherwise, proceed to close his abdomen. CLOSURE. Close his abdomen securely with non-absorbable sutures in a single layer (9.8), because it is particularly likely to burst (9.13). Don't insert drains. POSTOPERATIVELY. Nurse him sitting up in a high Fowler's po- sition. He will breathe more easily, he will be less likely to have chest complications, and any exudate will gravitate downwards. Continue with nasogastic suction and intravenous fluids, as in Sections 9.9 and A 15.5. Replace gastric aspirate with 0.9% saline. If he is likely to get lung complications (9.11), chest physiotherapy is vital. DIFFICULTIES WITH A PERFORATED PEPTIC UCER If a patient who is VOMITING for any reason suddenly feels a severe pain in his epigastrium and behind his lower sternum, or spread- ing between his shoulders, suspect that he has a RUPTURED OESOPHAGUS, and see Section 25.16. If his ulcer is BURROWING INTO HIS LIVER, separate his stomach or his duodenum from his liver by pinching between them with your finger and thumb. If this is difficult, or it is leaking into his perito- neal cavity, cut around it, and leave its base fixed to his liver. If you have been able to separate it from his liver, deal with it as usual. If you are experienced and he is fit, partial gastrectomy (not described here) is appropriate. CAUTION! Don't put your finger through his ulcer into his liver, it will bleed severely. If he runs a FEVER in the second week, suspect that he has a subphrenic abscess (6.4). If you continue to obtain MUCH GASTRIC ASPIRATE, he probably has pyloric stenosis aggravated by the suture. If it continues for more than 10 days, and you are competent to do so, do a gastroentero- stomy and truncal vagotomy (a gastroentrostomy alone has a high incidence of anastomotic ulcers, except in women over 50).
Bleeding from upper gastrointestinal tract
In South and Central Africa, and in most of the developing world, a bleeding peptic ulcer is the commonest cause of bleed- ing from the upper intestinal tract, but there are parts of East Africa and India where bleeding varices as the result of portal hypertension are more common. They may be the result of cirrhosis of the liver, schistosomiasis causing noncirrhotic peri- portal fibrosis, or extrahepatic portal vein obstruction. Other causes of bleeding include stress ulcers, hiatus hernia, uraemia, gastric carcinoma, a tear in the lower oesophagus following a forceful vomit (the MalloryWeiss syndrome, 25.16), and multi- ple shallow erosions following aspirin or some other drugs. In all these conditions the patient vomits bright blood or 'coffee grounds', or he passes melaena stools, or occasionally bright blood, from his rectum. Aim to: (1) Resuscitate him, (2) make the diagnosis, (3) assess his risk status, and (4) control bleeding. Try to make the diagnosis epidemiologically and clinically, be- cause you are unlikely to have a fibre-optic gastroscope, al- though you may be able to do barium studies (34.5). The im- portant distinction is whether or not he has oesophageal varices, because you will not want to operate on these, whereas you may need to operate for most of the other causes. A large spleen is the most useful sign. Fortunately, in contrast to the situation in Western countries, if a patient in India has portal hypertension and oesophageal varices, he is unlikely to be bleeding from an ulcer. Even the best surgical centres cannot find a cause for the bleeding in about 10% of cases. You will need plenty of blood.
HISTORY. A history of peptic ulceration is suggestive only. There
is at least a 25% chance that the patient has a peptic ulcer and no
symptoms. Has he been taking aspirin, phenylbutazone, indo-
methacin, or steroids? All these can cause ulcers.
EXAMINATION. Look for signs of anaemia. A pulse of 120 or
more is a reliable sign of recent blood loss. Take his blood pres-
sure. If you are not sure if he is hypovolaemic or not, do the 'pulse
test' for orthostatic hypotension (66.1). Examine him for epigastric
tenderness. Examine him rectally to make sure that a history of
black tarry stools is correct. Look for malignant deposits. Measure
his blood urea.
DIAGNOSIS. The following three conditions account for 90% of
cases. Other causes, such as hiatus hernia, gastric carcinoma, or
the MalloryWeiss syndrome are rare (25.16).
Suggesting bleeding oesophageal varices --
a large spleen, a firm en-
larged irregular liver, or a small hard one; anastomotic vessels on
omentum brought up over the hole perforation closed with several interrupted sutures C B perforation in the anterior wall of the duodenum A PERFORATED PEPTIC ULCER his abdomen, ankle oedema. Ascites is common in cirrhosis, less common and often not marked in periportal fibrosis, and very uncommon in extrahepatic obstruction. Spider naevi, and palmar erythema are uncommon in India and Africa. He may be drowsy or in coma from hepatic encephalopathy (made worse by the digestion of the blood in his gut). His liver function tests are abnormal in cirrhosis, but are often normal in the other causes of bleeding varices. Suggesting a duodenal or gastric ulcer -- a history of epigastric pain. Suggesting gastric mucosal erosions -- the recent ingestion of alcohol or analgesic tablets. Suggesting Schistosomiasis mansoni causing periportal fibrosis -- he is from an endemic area and has a large liver, and blood in his stools. There is little point in looking for ova in a rectal snip, because in an endemic area everyone has them. Suggesting non-cirrhotic portal fibrosis or a thrombosed portal vein -- his only abnormal sign is an enlarged spleen. Use his history and physical signs to form some estimate of how much blood he has lost, and over how long. Decide if his blood loss has been mild, moderate, or severe. RESUSCITATION. Group and cross-match blood for him. Sedate him heavily 4-hourly with diazepam 5 to 10 mg intravenously, or chlorpromazine 25 mg. Avoid morphine. Cimetidine is of no value, because it does not affect bleeding. Depending on his condition, set up 1 or 2 intravenous drips of 0.9% saline or Ringer's lactate, with large-bore needles. If he has bled severely, give him 1 to 4 litres of fluid, or more, until his blood pressure returns to 100 mm Hg. He may need at least 3 units of blood and possibly many more. If you have a colloid plasma ex- pander, give him a litre or two while you wait for blood, or even continue with it, if HIV is a high risk in your area. If you don't have blood, or enough blood, don't hesitate to give him large quantities of saline or Ringer's lactate -- his great need is for fluid to fill his vessels. Pass a large nasogastric tube. This will tell you if he is continuing to bleed, and whether the blood is fresh or altered. If you aspirate clots, irrigate his stomach to wash them out. Then wash out his stomach with ice-cold saline containing noradrenalin every half hour until bleeding stops, as described below. Consider putting 500 mEq of sodium bicarbonate (A 15.1) down the tube 12-hourly. Or, give him magnesium trisilicate mixture 30 ml every 2 hours. MONITORING. Measure and chart his pulse, his blood pressure, and his peripheral circulation half-hourly. A rising pulse or a sus- tained tachycardia are more important than isolated readings. Monitor his urine output, and, if possible, his central venous pres- sure if he is very ill (A 19.2). Early measurements of his haemo- globin and haematocrit will be of little value, except as a baseline with which to compare later ones, because his blood will not yet have had time to dilute. Continued bleeding is suggested by: per- sistent nausea, tachycardia, pallor, restlessness, very active bowel sounds, and the failure of his haemoglobin to rise in spite of transfusion (a useful sign). THE OUTCOME. Several things can happen. A gastric ulcer or oesophageal varices are more likely to continue to bleed than a duodenal ulcer. Melaena alone is not as serious as haemate- mesis, but beware of continuing melaena and unaltered blood in the stools, which indicate continued bleeding. (1) He may stop bleeding either before he is admitted, or with the above treatment, and not bleed again (75% chance). (2) He may continue to bleed severely, and vomit up kidney-basin after kidney-basin of fresh or clotted blood, each bleed be-ing ac- companied by a wave of weakness and sweating. Or, he may continue to pass large tarry stools. He looks pale, his pulse is rapid (100), and his blood pressure low (90 mm), showing that you have been unable to make up for the blood that he has lost. (3) He may continue to bleed moderately, and respond to the trans- fusion, but continue to pass small melaena stools, or have small haematemeses, so that his haematocrit drifts downwards. His resting pulse may only be 90, but the least exertion may send it up to 120 or more. Non-operative treatment is dangerous if he stays like this for more than 72 hours. (4) Bleeding may stop completely and start again in a few hours, or a day or two later. This also is dangerous. The indicators of low risk and a favourable outcome are: melaena alone, no loss of consciousness, aged 45, BP 100 mm Hg, pulse 120/min. The indicators of high risk and an unfavourable outcome are: haemate- mesis, loss of consciousness, aged 45, BP 100 mmHg, pulse 120/min, bleeding varices. MANAGEMENT depends on his risk status. The following regime comes from India. If he is at low risk, put him to bed for a week, give him 30 ml or more of antacids 2 hourly. He may need 500 mEq of sodium bicarbonate 12-hourly. Later, if possible, refer him for a barium meal and endoscopy. If he is at high risk, management depends on whether or not you suspect varices. If you suspect varices, insert a Sengstaken tube for 48 hours, then deflate the balloon. If bleeding recurs, reinflate the balloon and refer him. If you don't suspect varices, continue conservative treatment. If this fails, operate on the indications given below. INDICATIONS FOR SURGERY. Situations (2), (3) and (4) above and blood shortage are the main indications for surgery. If you are going to operate do so immediately. If he is more than 45, he needs surgery all the more urgently, unless he has some other disease, such as cardiac failure. If he is not suitable for surgery, or for some reason you decide not to operate, there are two things that may help -- cold nor-adre- nalin lavage and, if you suspect varices, vasopressin. COLD NORADRENALIN LAVAGE. Over 10 min run 200 ml of ice- cold saline containing noradrenalin 8 mg into his stomach. Half an hour later, aspirate it and replace it. It will lower the temperature in his stomach, and may cause a bleeding vessel to constrict. A gastric ulcer has stopped bleeding when the fluid that comes out is no longer bloody. If this has not happened after 4 hours, abandon this method. If he has a duodenal ulcer, blood may not be returned in the effluent, so you will have on rely on his pulse and blood pressure to know when he has stopped bleeding. VASOPRESSIN. ('Pitressin') constricts the sphlanchnic blood vessels, and is more useful for varices than for an ulcer. Dilute 20 units in 500 ml and and give it over 23 hours. Warn him about its side-effects -- abdominal cramps, headache, and palpitations. It will also raise his blood pressure for a short time. Vasopressin loses its activity in the heat, so, if he does not get abdominal cramps, it is likely to be inactive.
The surgery for a bleeding peptic ulcer
If a patient has a bleeding peptic ulcer, there is about a 75% chance that it will stop bleeding spontaneously, if you treat him non-operatively by replacing the blood he loses, as in the previous section. If he does not bleed again after his admission to hospital, his chances of living are good. If non-operative treat- ment succeeds, he can, if necessary, have an elective operation for his ulcer later. There is however about a 25% chance that the time will come, when it looks as if transfusion alone is going to fail. At this point you will have to decide whether or not to oper- ate in the hope of saving his life. If he needs surgery, on the indi- cations in the previous section, and he does not get it, he has about a 50% chance of death, especially if he is over 45. If you operate skillfully, his chances of death are only about 10%. In spite of the limitations of your services, about 90% of your pati- ents with severe bleeding should live, most of them as the result of your efforts. One of your main difficulties will be to get enough blood. The purpose of emergency surgery is to save his life, so you will have to decide when he is more likely to die if you don't operate than if you do. Try, especially, to judge the best time to operate. When you operate, try to find where the blood is coming from, and stop it. Doing an operation which will prevent it recurring is a lesser priority, because you may be able to refer him to some- one else for a definitive operation later. If you decide to operate, you will have to open his stomach and duodenum. If you find a bleeding duodenal or gastric ulcer, the simplest way to stop it bleeding is to underrun it. At the same time, you can -- if you feel competent enough, and he is fit enough -- take the opportunity to do a vagotomy and a pyloroplasty or gastroentrostomy, which will reduce the chances of recurrent ulceration afterwards. Cutting his vagus will reduce the acid his stomach secretes, but it will also hinder its empty- ing. A pyloroplasty will correct this by making a wide opening into his duodenum, through which his stomach can empty more easily. A pyloroplasty also helps a duodenal ulcer, but it should be combined with a vagotomy. Surgery for gastrointestinal bleeding is difficult. The two com- mon mistakes are: (1) To choose the wrong patients to operate on. (2) To operate at the wrong time[md]if you wait too long, you risk the patient's life, but if you operate too soon, the risk may be equally great, especially if you operate before you have restored his blood volume. Be much more ready to operate if he is over 45, and if he is bleeding moderately or severely. The bleeding point may be difficult to find, and when you have found it, blood may obscure it, so that controlling it will be diffi- cult. You will need a large opening in his stomach (gastrotomy), a good assistant, a good light, and good suction. ANATOMY. The oesophagus continues inside the abdominal cavity for about 2 cm before it joins the stomach. One vagus nerve lies under the peritoneum in front of the oesophagus, and one behind it, not quite so close to it. Both of them lie slightly towards the right, and both usually divide into several branches at the point where the oesophagus joins the stomach. Sometimes the anterior vagus, and less often the posterior one, divide into branches before they pierce the diaphragm. So don't be content with only finding a single trunk. These nerves are more easily felt than seen.
INDICATIONS. If a patient is in group (3) or (4) in the 'Indications
for Surgery' in Section 11.3, you should be able to prepare him
adequately for surgery. Blood will surely be scarce, and HIV may
be a problem, but you should try to restore his haematocrit to 30%
before you operate, and have 2 or 3 units of blood ready for the
operation. A patient in group (2) requires so much blood that pro-
viding it will be a severe strain on your blood bank; even so, you
should try.
ANAESTHETIC. Intubate him and give him a general anasthetic.
Leave a nasogastric tube in place. The anaesthetist must realize
that there may still be clots in his stomach. Find two assistants in
addition to the trolley nurse.
WHERE IS HE BLEEDING FROM? Make a high midline incision
extending up to his xiphisternum. Open his abdomen, and insert a
self-retaining retractor in his abdominal wall. Insert a deep retrac-
tor under his liver, so that your assistant can retract it upwards.
Gently draw the greater curve of his stomach downwards.
Suggesting peptic ulceration --
a scarred, deformed first part of his
duodenum; a puckered, thickened, hyperaemic area on his
stomach, especially on the lesser curve. There may be nothing to
feel if a posterior ulcer is eroding into his pancreas.
Suggesting bleeding oesophageal varices --
a firm or hard, shrunken,
irregular liver, and dilated veins on his stomach. If you find this,
and there are no signs of an ulcer also, close his abdomen, and
treat him as in Section 11.5. Sometimes a patient has varices and
an ulcer.
IF THERE IS NO OBVIOUS BLEEDING SITE, feel every part of
his stomach between your thumb and forefinger, and go right up
to his gastro-oesophageal junction. Open his lesser sac by divid-
ing his greater omentum between the lower edge of his stomach
and his colon. Feel the whole posterior surface of his stomach.
You may fail to find the source of the bleeding, or to control it, but
unless you try, the chances of his surviving are small.
If you still cannot find the source of his bleeding, and he has been having
melaena stools,
check his small gut first. Blood might be coming
from anywhere from his duodeno-jejunal flexure to his caecum. If
you are not sure if the contents of his gut are blood or bile insert a
needle obliquely and aspirate them. Look for a bleeding leio-
myoma of the stomach or small intest-ine, or a bleeding Meckel's
diverticulum. Then check his colon for ileocaecal tuberculosis,
carcinoma, amoebic colitis, and intussusception, etc.
If, even after you have done this, you cannot find the source of the
bleeding, and he has vomited blood,
open his stomach and duo-
denum. There is no substitute for having a good look.
Alternatively, if you have a cystoscope,
consider inserting this into his
stomach through a purse string suture. You can see into the se-
cond part of his duodenum, and up into his oesophagus. You may
have to wash out his stomach to get a clear view.
OPENING THE STOMACH AND DUODENUM IN
GASTROINTESTINAL BLEEDING
Insert moist packs to seal off his abdominal cavity. You have a
choice of two incisions, depending on the degree of fibrosis of his
duodenum.
If the scarring and fibrosis of his duodenum is mild or absent,
make a
linear incision as in A, Fig. 11-3 with 3/5 of it in his stomach, and
2/5 in his duodenum.
If the scarring and fibrosis of his duodenum is severe,
make a Y-shaped
incision as in E, Fig. 11-3.
Make your linear or Y-shaped incision through the serous and
muscular coats of the anterior wall of his stomach, starting 4 cm
proximal to his pylorus, and extending over the front of the first
and second parts of his duodenum for 3 cm beyond his pylorus. If
he has an ulcer, centre the linear incision on this, and make it
about 1 cm above the lower border of his stomach and duode-
num, as in (A).
Use tissue forceps and a scalpel to make a nick through the mu-
cosa of the gastric end of the incision, so as to open his stomach.
Enlarge the opening a little with scissors. Slowly cut through the
remaining mucosa with scissors. Pick up bleeding points as you
reach them, or bleeding from the incision will obscure everything.
If there are too many haemostats, run a continuous layer of catgut
along each side of the incision, and tie the bleeding points.
Inspect the inside of his stomach and duodenum. Mop out clots,
and suck out fresh blood, trying to see where it is coming from.
Evert the mucosal layer with Babcock forceps. Place a deep re-
tractor in the upper end of the opening in his stomach and ask
your assistant to expose as much of its interior as he can. If ne-
cessary, extend the incision 2 to 5 cm proximally. Is there blood
trickling down from anywhere? Feel the inside of his stomach. You
may see or feel: (1) An artery spurting from an ulcer on the
posterior wall of the first part of his duodenum (the common site),
or round the corner in its second part. (2) An ulcer anywhere in
his stomach. (3) Shallow erosions, high on the lesser curve.
If he has had a haematemesis and you cannot find any abnormality:
(1)
Try to look at his gastro-oesophageal junction from inside his
stomach. Make a high longitudinal gastrotomy up to the cardia.
You may see oesophageal varices, or forceful vomiting may have
produced a MalloryWeiss tear of his lower oesophagus (see
below and 25.16). (2) Put the tip of the sucker, or a swab on a
holder, into the second part of his duodenum, to make sure that
he is not bleeding from a postbulbar ulcer.
If you still cannot find any cause for the bleeding, close the in-
cisions in his stomach and his abdomen. Some surgeons would
do a truncal vagotomy and a gastroenterostomy, or a pyloro-
plasty.
If you find an acute ulcer, a solitary erosion, or multiple small bleeding
erosions,
do a truncal vagotomy and gastroenterostomy, or a
pyloroplasty. Postoperatively, warn him not to take drugs con-
taining aspirin.
A CHRONIC BLEEDING ULCER AT LAPAROTOMY
Control bleeding from a chronic duodenal ulcer by underrunning
it. Retract the edges of the V-shaped pyloroplasty incision. Using
chromic catgut in the stomach and silk in the duodenum on a
curved needle, pass 2 or 3 stitches deep to the ulcer, as in B, Fig.
11-3. Tie the sutures so that you stop the bleeding. Ask your as-
sistant to keep the area dry, and be sure to go deep enough to
include the walls and base of the ulcer, but not so deep that you
catch important structures, such as the common bile duct. Tie the
sutures tight, but not so tight that they cut out.
If you don't feel happy about doing a vagotomy,
do a pyloroplasty, and
refer him for a definitive vagotomy later.
PYLOROPLASTY (HeinickeMiculicz)
INDICATIONS. (1) A bleeding duodenal ulcer. (2) For other com-
plications of a duodenal ulcer, see 11.2.
METHOD. First make sure bleeding is controlled as described
above. The kind of pyloroplasty you should make will depend on
the kind of incision you made, which in turn depended on the
severity of the fibrosis you found.
If you made a linear incision,
because there was only mild fibrosis,
hold it open with stay sutures. Pull on these so as to elongate it
transversely, and close it with close 2/0 chromic catgut sutures
through the mucosa and serosa.
If you made a Y-shaped incision,
because there was much fibrosis,
either: (1) Close it as you found it, and do a gastroenterostomy.
Or, (2) sew it up as a 'V', as in G, and H, Fig. 11-3.
Finally, with both incisions, bring up a tag of omentum and fix this
across the suture line with a few sutures which pick up only the
seromuscular layer (C, 11-2).
VAGOTOMY FOR PEPTIC ULCERATION
Postpone this if his condition does not permit it -- you have al- ready done the life saving part of the operation. You must get adequate access. This may be difficult if he is fat, or has a deep chest, or if the left lobe of his liver is large. Extend the abdominal incision right up into the notch between his costal margin and his xiphisternum. Ask your assistant to lift up his left costal margin with a deep gauze-covered retractor. With your right hand draw his stomach and colon downwards, and keep them packed down with 2 or 3 large moist abdominal packs. Feel for the short abdominal part of his oesophagus, and for the nasogastric tube running through it. Or slide your hand upwards over the fundus and body of his stomach, until you reach his dia- phragm, and then feel for his oesophagus. You have now to free the left lobe of his liver from his dia-phragm. Grasp its free edge between the index and middle finger of your pronated left hand, and pull it downwards and medially. This will reveal his left triangular ligament attaching this part of his liver to his diaphragm. Under good vision and with a long pair of scissors cut about 4 to 6 cm of this bloodless attachment from left to right, making sure that you do not go too far medially (B, in Fig. 11-4), because his inferior vena cava is there. Then reflect the left lobe of his liver medially and to the right, and hold it there with a deep (Deaver's) retractor over a large pack (C). Pick up the peritoneum over his oesophagus with a long (25 cm) haemostat, and use scissors, or a long-handled scalpel with a small blade, to make a very superficial 2 cm transverse or longitudinal incision in it, just above its junction with his stomach. CAUTION! (1) Cut his peritoneum only. This is a thin layer. Don't cut the muscle of his oesophagus. (2) Don't cut any of the bran- ches of his left gastric vein, on the right margin of his stomach. Using gauze on a sponge holder (D), gently push away the perito- neum from the site of the incision, so exposing the front of his oesophagus (E). Dissecting with your right index, and repeatedly spreading your index and middle finger to open up tissue planes, free his oesophagus from the areolar tissue holding it to the right crus of his diaphragm and his aorta. If you dissect like this there is little chance of your tearing blood vessels, or damaging his oeso- phagus. But, don't 'finger dissect' too close to his oesophagus posteriorly, or you will push his posterior vagus nerve away from it, so that finding it will be difficult. Stay close to the crus, espe- cially as you dissect towards the right side of his oesophagus. On the right your finger may be arrested by peritoneal folds and small vessels. Persist with blunt dissection, and resist the urge to cut anything, until you have gone all round his oesophagus with your finger. Gently draw his oesophagus downwards until you can feel 45 cm of it. Pass a long curved clamp, such as a Lahey, behind his mo- bilized oesophagus, and use it to draw a soft catheter, or naso- gastric tube, through and around it, so that you can pull on it (F). This will help to expose the site better, and will hold the vagus taut, so you can feel it. Feel for his anterior vagus nerve. You may see it as a fine white strand running down in front of the central part of his oesophagus, but it is usually easier to feel (G). Run your right index finger across his oesophagus -- feel for a taut thread or fine cord, quite different from anything else. Follow it up to where it emerges from under the crus of his diaphragm. Place a long O'Shaughnessy or
PYLOROPLASTY A 2/5 3/5 B C D E F G p q H Lahey haemostat on the nerve and draw it down slightly, to make sure that it does not have any branches. Apply another long clamp just distal to the first, and cut the vagus between them. Draw the second clamp and the vagus downwards, and cut off a 1 cm segment of the nerve (H and I). Search the anterior aspect of his oesophagus for other branches of his vagus -- incomplete vagotomy is the commonest reason why the operation fails. Look for his posterior vagus nerve -- it is harder to find, but is larger. If your dissection has been adequate, you should find it. Pass a finger of your right hand round the back of his oesophagus, and feel for the thick cord of his posterior vagus, just behind the right edge of his oesophagus. Try lifting it forwards over the tip of your finger (J); then clean away any obscuring strands of tissue with a pledget of gauze on the end of a sponge forceps. You should be able to expose a short section of it without rupturing any of the small veins. Remove a piece of his posterior vagus as you did his anterior one (K), and look for accessory branches. Control minor bleeding by packing his subphrenic area with warm moist packs for a few minutes. Control more active bleeding by ligation. CAUTION! Feel for these nerves, pull them up on a finger, see them, and then cut them. Remove the sling round his oesophagus. Close his abdomen, preferably in a single layer by Everett's or Goligher's methods (9.8). Don't insert a drain, unless you are worried about the safety of the anastomosis of his pyloroplasty. He has bled severely, and his wound is likely to heal poorly. If it breaks down, he will be in danger. 'Suck and drip him', and replace his gastric aspirate, as usual (9.9, A 15.5). If his postoperative haematocrit is less than 35%, transfuse him. DIFFICULTIES WITH GASTROINTESTINAL BLEEDING Expect respiratory complications (9.11), and wound breakdown (9.13). If the BLEEDING POINT IN HIS DUODENUM IS OBSCURED BY BLOOD, apply warm packs and pressure, and wait 10 minutes. If BLEEDING RESTARTS after the operation, manage him nonopera- tively, or refer him; don't try to explore him again. If you find what looks like a MALIGNANT GASTRIC ULCER, adapt what you do to the size of the lesion: If the lesion is small, do a local excision with a 2 cm margin, and repair the defect in two layers. If the lesion is advanced, take a biopsy, and if it has metastasized to lymph nodes or his liver, refer him for more radical surgery later if you can. If he BLED AFTER A SEVERE INJURY, or a burn, a head injury, or a major surgical operation, or he is an alcoholic or takes drugs, such as aspirin, indomethacin, or phenylbutazone, suspect STRESS ULCERS (super- ficial erosions in the stomach or typically in the second or third parts of the duodenum). These are usually multiple, shallow, and irregular. He will have had little pain, and severe bleeding is likely to have been the first sign. Minor harmless gastric bleeding is common after an alcoholic bout. Ulceration of this kind may ooze severely, so that he has melaena stools for several days. Give him antacids half-hourly, and try a noradrenalin in saline lavage (11.3) and, if possible, intravenous cimetidine. Don't operate if you can avoid doing so. If you have to operate, do a vagotomy and gastro- enterostomy. His chances of dying are high, whatever you do. If you are giving him cimetidine intravenously, give him 100200 mg/hour for 2 hours repeated after an interval of 46 hours. Or, 400 mg in 100 ml of 0.9% sodium chloride infused over half to one hour, repeated after 46 hours. Or, by continuous infusion at an average rate of 50100 mg/hour over 24 hours, maximum 2.4 g daily. If he started to BLEED AFTER A SEVERE EPISODE OF VOMITING from some other cause, such as a drinking bout, suspect that he has a tear in his oesophagus at, or just above, his gastro-oesophageal junc- tion (the Mallory-Weiss syndrome). See Section 25.16. If you ENTER HIS OESOPHAGUS DURING A VAGOTOMY (which should never happen!), repair the tear as in Section 25.16 and Fig 25-12.
Bleeding oesophageal varcies
A patient who is bleeding from the rupture of his oesophageal varices will be such a formidable challenge to you, that stopping it may be impossible. You will not be able to do a portacaval shunt, or to suture them with an automatic stapling instrument, so you will have to rely on plenty of blood and a Sengstaken tube to compress them. If he has cirrhosis, his prognosis outside a major centre will be so bad, and he will need so much blood, that you may not feel justified in treating him. Dilated varices are the result of a high pressure in his portal venous system -- more than 18 cm of saline. The common causes are: (1) cirrhosis of his liver, (2) periportal fibrosis due to S. mansoni infection, (3) noncirrhotic portal fibrosis, and (4) thrombosis of his portal vein. He dies from loss of blood and loss of liver function. The final cause of his death may be hepa- tic encephalopathy, due to the failure of his liver to detoxify the breakdown products from the blood in his gut, either because its cells have failed, or because blood has been shunted from his liver. Liver failure commonly complicates cirrhosis, but not the other causes. Aim to: (1) stop him bleeding, (2) restore his blood volume, and (3) prevent encephalopathy. · TUBE Sengstaken, 18 and 21 Ch, two only of each size. This has 3 channels and two balloons. You will need this tube if bleeding oeso- phageal varices are common in your area. It will usually control bleeding while the tube is in place, and bleeding may stop after it is removed. One danger is that a balloon may displace into the patient's glottis and ob- struct his respiration. If you don't have a Sengstaken tube, you may be able to use a Foley catheter with a 30 ml balloon.
WHEN THE PATIENT IS NOT BLEEDING If you see him between bleeds, do his liver function tests. Do a barium swallow with a thick suspension of barium to demonstrate the varices. If necessary, examine a rectal snip. Give him 3 injec- tions of vitamin K 10 mg daily for 5 days. WHEN HE IS BLEEDING PREVENT ENCEPHALOPATHY. Give him a saline purge through the Sengstaken tube. Empty his large gut with an enema, and give him oral neomycin 1 g 4 to 6-hourly to reduce the bacterial activity in his gut. Don't give him any protein by mouth. DRUG CONTROL OF BLEEDING. Vasopressin ('Pitressin') will reduce his portal venous pressure by constricting his sphlanchnic arterioles. See Section 11.3. SENGSTAKEN TUBE. Measure the capacity of the two balloons, and check that neither of them leak. The distal gastric balloon of a large tube holds about 120 ml. Inflate the oesophageal one to 30 mm Hg, checked against an ordinary sphygmomanometer. Add the contents of 2 ampoules of 45% 'Hypaque' (or a similar con- trast medium) to 250 ml of saline. Have a sucker available. Local anaesthesia of his mouth and pha- rynx may be helpful. Lay him on his side, and pass the tube quick- ly through his mouth into his stomach. Inflate the gastric balloon with the saline/hypaque mixture. Withdraw it until it impacts against his cardia, and take an X-ray film to check its position. In- flate the oesophageal balloon to 30 mm Hg. Tie a thread round the tube opposite his lips to mark the correct position of the balloons. Aspirating the tube will show you if he has stopped bleeding. Use it to give him a mixture of magnesium hydroxide, neomycin, and glucose. He will be unable to swallow his saliva, so lay him on his side to let it dribble frm his lips, and have a nurse always available to suck out his mouth, if necessary. After 24 hours deflate the oesophageal balloon, then the gastric one, and continue to aspirate his stomach. If he starts bleeding VAGOTOMY A B C D E F G H I J K L again, you can apply the tube for a further 12 hours, but this is a sign that he should have surgery -- if this is possible. CAUTION! (1) If the tube displaces upwards, it may obstruct his glottis. Warn the nurses about this, and tell them to remove it quickly if it does so. (2) Deflate the tube after 48 hours. Don't leave it in any longer, because his mucosa will necrose. (3) If you continue to aspirate fresh blood, reconsider your diagnosis. (4) Don't take a needle biopsy of his liver while he is in the acute bleeding stage. A FOLEY CATHETER is less satisfactory. Pass this through his mouth, inflate the balloon, and draw it upwards so that it presses against the varices at his gastro-oesophageal junction. Either tape the catheter to his cheek, or, better, tie it to a weight suspended from a pulley. DIFFICULTIES WITH BLEEDING VARICES If he BLEEDS AGAIN after you have removed the tube, his prognosis is not good, but varies with the cause of his varices. If he is cirrhotic, his prognosis is bad. If his RECTAL SNIP IS POSITIVE for Schistosoma mansoni, or he is excreting ova in his stools, this may be the cause of his symptoms. Unfortunately, in an endemic area most of the population will have ova in their stools. Live ova, detected by a concentration test if ne- cessary, are more significant than dead ones. If however he does have periportal cirrhosis due to this worm, his liver function is likely to be good, and his prognosis will not be so bad -- if you can refer him to a centre where he can have a portosystemic shunt, or a course of sclerotherapy. This is probably only justified if he is under 50, has no jaundice or ascites, and his serum albu- men is above 3 g/dl. If his PORTAL VEIN HAS THROMBOSED, or he has NON-CIRRHOTIC PORTAL FIBROSIS, he will probably have a normal liver, and his bleeding will eventually stop. Refer him if you can.
Pyloric stenosis
The scarring around a patient's duodenal ulcer sometimes obstructs his pylorus, especially if he does not have his earlier ulcer symptoms treated. He may come to you saying that he has been vomiting for days or weeks. He may only vomit once a day, or he may say that he vomits everything he eats. His vomit may contain food that he ate days before. Or, he may not actually vomit, but merely feel abnormally full and bloated after only small amounts of food. He may have eructations, and he may have taught himself to vomit to relieve his symptoms. He loses weight. Continued vomiting depletes his extracellular fluid, and causes hypoclhoraemic alkalosis, and hypokalaemia; eventually he becomes dehydrated and oliguric. Occasionally, he may improve with a few days of conservative treatment, so that he is able to eat without feeling nauseated. If he does, don't press him to let you operate. He is unlikely to im- prove permanently. But if he has been vomiting for many days, and is starved and dehydrated with a huge dilated stomach, oper- ate as soon as you have corrected his fluid and electrolyte de- ficit. When you operate, do a vagotomy and a gastrojejunostomy, which is a side-to-side anastomosis between the antrum of his stomach and his jejunum. This will be easier than doing a pylo- roplasty (11.4) when his duodenum is very scarred, as it usually is in the developing world. In India and Africa a gastroentero- stomy may be better than a pyloroplasty, even if his duodenum is not much scarred at the time of surgery, because it may scar later. A retrocolic gastroenterostomy is better than an antecolic one, because the loop of jejunum to be brought up to the sto- mach is shorter, and there is no abnormal hole in his mesentery, through which loops of gut can herniate and twist. Make the stoma vertical so that it drains more easily. His duodenal ulcer may be anterior or posterior. The other important cause of stenosis of his distal stomach is carcinoma, see Section 32.25.
EXAMINATION. Lay the patient down and look for visible peri- stalsis, as his stomach struggles to empty itself through his narrowed pylorus. Look for slow waves moving from his left hypo- chondrium towards and beyond his umbilicus. Rock him from side to side. You may hear hear a succussion splash. You may also hear it if you depress his epigastrium sharply with your hand (a splash may be normal after a large meal). WASHOUTS will empty his stomach, remove debris, and rest it. With luck, his inflamed and oedematous pylorus will open up. Washouts, as in Fig. 25-11, will also reduce the risk of postopera- tive infection.
varices Find a funnel, a large (36 Ch, about 1 cm diameter) stomach tube or a catheter, and a longer piece of rubber connecting tube the same size. Lay him supine with his head supported over the end of the bed, as in Fig. 25-11. Pass the well-lubricated stomach tube through his mouth and encourage him to swallow it. Connect the stomach tube via the other tube to the funnel. Hold up the funnel and pour in 500 ml of water. Before the last drop has left the fun- nel, lower it over a bucket (to prevent air entering). His stomach contents will run out. Repeat the process, this time using a litre of water. Go on doing this until the fluid returns clear. Finally, leave 500 ml inside him. Repeat this daily, for 3 days, or until he is fit for surgery, which- ever is later. Don't wash him out on the day of the operation. FOOD. Give him any convenient fluid diet, such as milk with add- ed sugar, but don't give him anything to eat. X-RAYS are useful if the diagnosis is in doubt. Take an erect ab- dominal film, and look for a large fluid level in his left upper quad- rant. A drink of barium will produce a mottled shadow showing that his gastric outline is much enlarged. Little or no barium passes his pylorus. Don't give him a large quantity, because it may be difficult to wash out. NON-OPERATIVE TREATMENT FOR PYLORIC STENOSIS REHYDRATION, may be necessary over several days to restore his extracellular fluid volume. Use the methods in A 15.3. Give him 0.9% saline or Ringer's lactate. If necessary, correct his po- tassium loss with up to 80 mmol of potassium daily, or use Darrow's solution (K + 34 mmol/litre). Be guided by the volume and specific gravity of his urine output. GASTROENTEROSTOMY FOR PYLORIC STENOSIS INDICATIONS. (1) Pyloric obstruction causing dehydration and weight loss, or other long-standing obstructive symptoms as de- scribed above. (2) Duodenal ulceration with sufficient scarring to contraindicate pyloroplasty; combine it with a truncal vagotomy. (3) As a palliative procedure for stenosis caused by an antral car- cinoma. (4) For a duodenal ulcer in a woman of over 60. ANAESTHESIA. Give him a general anaesthetic with a muscle relaxant (A 14.3). POSITION. Lay him supine with his upper abdomen pushed for- ward by 'breaking the table', or by putting a pillow under his back. INCISION. Make an upper midline incision, or, if he has well de- veloped muscles, a right upper paramedian one. If you find a large thick walled stomach, the diagnosis of pyloric stenosis is confirmed. Ask your assistant to retract his liver up- wards with a deep retractor, and to draw his stomach downwards at the same time. Is the obstruction malignant? First, try to make sure that he has not got a carcinoma of his pylorus. If he has lumps and nodules, en- larged hard lymph nodes, and perhaps an ulcer crater, just proxi- mal to his pylorus, suspect a carcinoma. Biopsy a node. He has probably got a chronic duodenal ulcer if he has: (1) Puckered scarring on the front of the first part of his duodenum, perhaps with adhesions to surrounding structures. (2) An indentation on the posterior wall of his stomach extending into his pancreas to which it is fixed. Carcinoma does not attack the first part of the duodenum, so that lesions there are almost certainly benign. If you are not sure what is obstructing the outlet of his stomach, do a gastroenterostomy and biopsy a regional node. Don't biopsy his stomach itself unless you intend to resect it. If you find a carci- noma, you can refer him for definitive surgery later -- if the tu- mour is resectable (no spread to his liver or to nodes beyond those on the greater and lesser curves of his stomach). See Section 32.25. METHOD FOR GASTROENTEROSTOMY. Start by doing a vago- tomy (11.4), if this is indicated. Ask your assistant to lift up the patients's transverse colon with both his hands, so as to expose the posterior layer of his trans- verse mesocolon. Find his middle colic vessels. You will see the posterior wall of his stomach through his mesocolon (A, in Fig. 11- 6). If he is thin, you will see it easily; if he is fat, it will be easier to feel. Apply Babcock's forceps to the posterior aspect of his stomach about 6 cm apart (B). Take up his mesocolon in the bite in an area well to the left of his middle colic vesels, leaving enough room for his jejunum to be brought alongside. Using the Babcock's as markers, push his stomach through his mesocolon from above. CAUTION! Make sure that the Babcock forceps are not too near any lesion he may have on the greater curve of his stomach. Find his upper jejunum and apply Babcock forceps to that. The first should be about 8 cm from his duodeno-jejunal flexure, and the second about 6 cm distal to that (B). Apply a non-crushing clamp as shown (C), to hold two-thirds of the width of the gut. Insert stay sutures through the seromuscular coats of his stomach and jejunum at each end, going through his mesocolon. His sto- mach wall is likely to be thick, perhaps very thick, if his pyloric stenosis is long-standing. Continue the layer of interrupted seromuscular sutures using 2/0 multifilament silk (D). Carefully incise the muscle of his stomach. This will reveal some blood vessels. Doubly tie these with 2/0 silk or smaller (E), and divide them between the ties. Open his stomach by cutting its mucosa, for about 3 fingers length (5 cm). Then, open his jejunum for an equal length, half way between the suture line and the clamp (F). Use 2/0 atraumatic catgut for the 'all coats' layer (G), starting at one end with an inverting Connell stitch, in the same way as for a side-to-side anastomosis. See Fig. 9-12. CAUTION! (1) Be sure to include all layers of his stomach wall in the anastomosis. If it is hypertrophied, the cut edges of its muco- sa will curl away. If you fail to include them in your sutures, they may bleed, or the suture line may leak. (2) Take care not to rup- ture his spleen, or his gastrosplenic vessels by pulling on his stomach too much -- make sure you have adequate exposure. Continue the suture along the posterior layer of the anastomosis, and do an inverting suture at the end (H). Then do the anterior layer (I), using a simple over-and-over suture and ending with a Connell inverting stitch (J). Tie the ends of the suture together and and cut them 0.5 cm distal to the knot. Insert a layer of interrupted sutures through the seromuscular coats of his stomach and jejunum, picking up his mesocolon with them (K). Remove the clamp, and feel the size of the stoma: it should admit 2 or 3 fingers (L). Replace his transverse colon in his abdomen. DIFFICULTIES WITH A GASTROENTEROSTOMY If his PEPTIC ULCER SYMPTOMS recur, you have not been successful in cutting all the branches of his vagus. An incomplete vagotomy is the main reason why this operation fails. If possible, give him a course of cimetidine, 200 mg three times a day and 400 mg at night for 4 weeks. If not try medical treatment with antacids (11.1). If his pain is not relieved, or he bleeds sigificantly, refer him.
If you CONTINUE TO ASPIRATE A LITRE OR MORE OF FLUID after the operation, the stoma is not functioning, or he has paralytic ileus. Bowel sounds and the absence of abdominal distension will ex- clude the latter. The stoma will be less likely to obstruct, if you make it big enough to take three fingers. It may remain obstructed for 2 weeks. Continue nasogastric suction, unless there is an indi- cation to reoperate (10.13), and give him parenteral fluids. His stoma is almost certain to open eventually. If, some time after the operation, he STARTS TO VOMIT BILE, reassure him. Bile and pancreatic juice are accumulating in the afferent loop, and when they are suddenly released into his stomach, he vomits. His symptoms will probably improve with time. If they don't improve in 2 years, consider referring him for a revision proce- dure.
Elective surgery for chronic duodenal ulcer
If a patient has 'peptic ulcer disease', you can usually treat him by medical treatment with diet and antacids, and by persuading him to abandon alcohol and cigarettes. Unfortunately, you are unlikely to be able to give him the expensive H -receptor anta- gonists, cimetidine or ranitidine, because he cannot afford them. So, if inexpensive medical treatment fails, the only way you can help a poor patient may be to operate. If he has uncontrollable pain and dyspepsia, or if his quality of life has been spoilt over the years by nagging pain, heartburn, and indigestion, do a truncal vagotomy and gastroenterostomy or pyloroplasty (11.4), as an elective procedure, especially if he is older and has atypi- cal symptoms. He may have a gastric ulcer, with its higher rate of complications and recurrence. Don't wait until he has a severe bleed, or the overwhelming vomiting of pyloric obstruction. You will not have an endoscope, and may not be able to do barium studies, so you will only be able to confirm the diagnosis at laparotomy. The absolute indications for operation are: (1) perforation, (2) a continuing or recurrent haematemesis, (3) pyloric stenosis, (4) suspicions of carcinoma -- if he is fit enough. Otherwise, he is likely to be the best judge as to whether he should undergo surgery or not -- provided he is not neurotic! Your methods for investigating him will be limited, so when you do a laparotomy, expect to find that your preoperative diagnosis was wrong. What you thought was a duodenal ulcer may be chronic cholecystitis, carcinoma of his stomach, chronic pancre- atitis, or some other abdominal condition.
Gastrostomy (Stamm)
If a patient's oesophagus is obstructed, he cannot swallow food, so he starves. He cannot swallow saliva, so it drips from his mouth. You can feed him through an opening in his stomach, but this will not help him to swallow his saliva. This is such a dis- abling symptom, that there is little to be gained by prolonging his life merely to endure it. There is thus seldom any indication for doing a gastrostomy for inoperable carcinoma of the oeso- phagus or pharynx. The possible indications for it are given be- low. For many of them a jejunostomy is an alternative. GASTROSTOMY
INDICATIONS. (1) Strictures of a patient's oesophagus following corrosive poisoning, prior to referral for reconstruction. (2) A malignant stricture of his oesophagus or gastro-oesophageal junction, with no signs of advanced disease, and when you plan to insert a Celestin tube. (3) Operable oesophageal carcinoma to 'build him up' before referring him for resection. (4) Diseases of his pharynx or larynx which make swallowing impossible, but which can be cured (for example, retropharyngeal abscess or per- foration from a fish bone). (5) Temporary postoperative drainage of his stomach, when a nasogastric tube is impractical. (6) Inoper- able carcinoma of the oesophagus is seldom considered a suit- able indication, see above and Section 32.24. METHOD. Under local or general anaesthesia make a small upper median incision (9.2). Pick up the cut edges of his peritone- um and draw them apart. You will probably find that his stomach is small and tubular, so that the first thing that you see is is his great omentum or transverse colon. Pull this downwards and de- liver the upper part of his stomach into the wound. CAUTION! Check that you really have found his stomach, and not his transverse colon by mistake! Make a small stab wound beside the median incision and use a haemostat to pull a 12 or 14 Ch Foley catheter through it. Make the gastrostomy high on the anterior wall of his stomach, midway between its greater and lesser curves, and as far from his pylorus as you can. Hold his stomach with two pairs of Babcock's forceps, and draw it upwards and forwards into a cone. Make a small inci- sion between the forceps, and push the catheter through this. En- circle it with 2 purse string sutures, and invaginate his stomach wall as you tie them. CAUTION! (1) Take the bites of the inner purse string suture through the full thickness of his stomach wall, so as to control bleeding. (2) The main dangers are haemorrhage and leaking. His gastrostomy must be as leak-proof as possible, so that his gastric juice does not enter his peritoneal cavity. Anchor his stomach above and below the tube to his parietal peri- toneum. Spigot the tube, and fix it to his skin with an encircling stitch. Before he leaves the theatre instil some fluid (milk if possible) through it, to make sure it is patent, and to start giving him the food he so badly needs.
