Showing papers in "Transactions of the Medical Society of London in 1954"

Surgery of peptic ulceration and its complications.

Abstract: Post-Gastrectomy Conditions Early post cibal symptoms. I have little to add to the vast amount which has been written on the aetiology of early post cibal symptoms or 'dumping '-that is symptoms of epigastric discomfort, sweating, flushing, palpitation and fatigue, sometimes biliary vomiting, appearing usually shortly after a meal, particularly a heavy meal in patients who have had a gastrectomy. I would, however, suggest that many of the symptoms are merely an exaggeration of the normal physiological response to over-eating. The reaction naturally comes sooner in the gastrectomized, because the capacity for taking food is reduced. Similar symptoms are occasionally encountered in persons who have had no operation, as a form of functional dyspepsia, and they may occur in persons who suddenly take a large meal after many hours or days of frugal meals. In prophylaxis, I commend the practice of explanation before the onset of symptoms. The sudden onset of flushing and palpitation during convalescence, shocks the patient and undermines his confidence and leads to apprehension and anxiety. If the patient has been told to expect these symptoms, and reassured that they will progressively diminish and that they do not imply the development of heart or other new trouble-then they are accepted calmly and are minimized rather than exaggerated. In treatment, the patient should be advised to resume normal meals as early as possible in order to hasten the time when the organism becomes adjusted to the new state of affairs. A period of recumbency should be taken if the symptoms occur, and the tea-time meal-the time when dumping is usually first complained of, should be made a small, dry, high protein, high fat meal-e.g., boiled egg, bread and butter with minimal fluid, or abandoned altogether. Certain cases are severe enough to require further surgical help. Surgery for post cibal symptoms should not; be undertaken less than a year from operation, for the symptoms usually abate with time and they may diminish even as late as after the third or fourth post-operative years. Flushing and palpitations rarely persist and the symptoms most likely to continue are biliary vomiting, which is not always post-prandial, inability to take certain articles of diet with comfort, notably milk or egg, and post-prandial diarrhoea. We have used six surgical procedures for persistent symptoms. i. Vagotomy. This was done several years ago in the belief that some of the symptoms might have been due to stimulation of vagus nerve endings in the suture line. This operation has produced no benefit in any case (eight altogether). 2. Short circuiting the afferent and efferent jejunal loops. This is done in the belief that discomfort is due to stasis of bile in the afferent jejunal loop, this belief being supported by the relief often obtained when bile is vomited. As the short circuit reduces the volume of biliary fluid entering the stomach and so increases the risk of stomal ulceration, we usually add a vagotomy. In the earlier four cases a two to three inch long stoma was made, but latterly in two cases we have used Steinberg's pantaloon operation, that is removing the whole spur between efferent and afferent loops right up to the stomach (Fig i6). This operation does diminish biliarv vomiting and tlhree of the cases were improved. None were made worse by it. 3. Conversion to a Roux type of stoma. In the Macarthur Lectures which I had the honour to deliver in Edinburgh in 1951, I mentioned the great benefit to be obtained by conversion to a Roux type of anastomosis when there was severe biliary regurgitation following end in side oesophago-jejunostomy after total gastrectomy (Tanner, I95I). I mentioned a simple method of affecting this (Fig. I7). A similar easy method is avaailable following partial gastrectomy,? 1;ut I pointed out that there was a great risk of stomal P rocted by coright.