Gastric Surgery.

NZMJ, 1924.

A paper read by F. S. Batchelor, F.R.C.S., at the Annual Conference of the British Medical Association (New Zealand Branch), at Auckland, 1924.

To begin with, a few words on the diagnosis and principles of treatment of gastric lesions. The majority of cases of duodenal ulcers can be correctly diagnosed by the typical history—certainly not all. Stomach ulcers do not carry such a clear-cut history. X-ray examination is, of course, of great value, but I do not believe that, certainly in Dunedin and probably in New Zealand generally, we have arrived at anything comparable to the exact X-ray diagnosis that is attained in America and England. I know that in the Mayo Clinic something over 90 per cent. of cancers and ulcers are correctly diagnosed by the X-ray specialists. I cannot put our results in accurate percentages, but would be surprised if they reached 50 per cent. The reason for this is obvious, and no doubt our X-ray diagnosis is steadily improving.

I cannot say that I have any profound diagnostic faith in chemical analysis of the stomach contents, although the modern fractional tests are a great advance on the single test meal, which was in many cases of little value.

I have nothing to say as to the etiology of these ulcers except to comment on the extreme frequency of the combination of ulcer and oral sepsis. The great majority of these cases either have, or have had, oral sepsis. This condition is extremely common in this country—I doubt if there is a higher incidence in any country in the world. It is obvious that no treatment, either medical or surgical, will reach its greatest value unless all septic foci are eliminated—a point that I am sure is frequently overlooked.

It is reasonable that in their early history innocent ulcers should be given a trial of medical treatment, and there can be no argument that some cases get well, and keep well, on such treatment, but when an ulcer becomes chronic and recurrent and when complications occur, then surgical measures are called for.

Surgical measures are indicated more speedily in gastric than in duodenal lesions because of the liability of the former to malignant changes.

Now, to come to the purely surgical part of the paper, taking first gastric carcinoma:—My experience of these cases has been very disappointing—one rarely gets a case in its early stage, and often not until there is a palpable tumour, by which time all chance of cure has disappeared. I do not see much hope of improvement unless all suspicious cases are explored in their early history, or until we are able to make an exact and early diagnosis by X-ray means and also to educate the public. Practically my only successes have been in cases where the growth was near the pylorus and causing obstruction, necessitating operation in a comparatively early stage.

In these cases a Bilroth number one, or more frequently Bilroth number two, with removal of the affected gland area are simple and safe operations, and give excellent results in suitable cases. I have at present three cases which show no signs of recurrence at the end of three years. In the more extensive cases I usually do an anterio and, more recently, a posterior Polya. By this method one can remove as much of the stomach as necessary—it is an operation of no outstanding difficulty and appears to me to be by far the most satisfactory operation for this class of case.

My immediate mortality has been quite reasonable—my end results in these cases have been very poor—I have not had a large operative experience of carcinoma of the stomach.

Turning now to non-malignant, or presumably non-malignant, ulcers. There is a group of acutely bleeding ulcers, Hale-White’s haemostaxis, which is not surgical. These cases usually have no characteristic ulcer history, and are probably due to some toxic infection, sometimes in connection with hepatitis, and are best treated by medical means, particularly stressing removal of septic foci.

In the more common chronic gastric ulcer surgical treatment should always include removal of the ulcer.

I am not a believer in large gastroectomies in all cases of gastric ulcer in the hands of the average surgeon—to which class I belong. I am positively certain that gastro-enterostomy only is a very inadequate procedure in these cases. Small ulcers of the stomach can be excised easily and safely with the knife or cautery, preferably the latter, but it is necessary to perform a gastro-enterostomy after such excisions to maintain proper peristalsis in the stomach.