How Much of the Stomach Should Be Cut Out?

Should Be Cut Out?

According to medical statistics, some 12 million Americans have, or have had, ulcers of the stomach or duodenum.

Every day, ulcers claim 4,000 new victims; every year, surgeons put about 150,000 ulcer patients on the operating table. There are half a dozen major types of surgery for ulcers, plus a dozen minor variants. Some of them are al most a century old, but physicians and surgeons still cannot concur on which type of operation is the best, or even which is best for any particular patient.

Last month specialists in Boston and New York reviewed the whole field in an effort to outline areas of agreement. They succeeded in illuminating the variety of argument.

Wanting in Elegance. Nobody knows the root cause of ulcers in the digestive tract, but what happens after the process gets started is fairly clear. Countless cells in the wall of the stomach secrete chemicals, such as gastrin, and hydrochloric acid. These are designed by nature for the digestion of food. But if for any reason--physical or emotional --the stomach cells churn out digestive juices when there is no food for them to work on, they may start digesting a spot on the wall of the stomach itself. The result is a gastric ulcer. More often, the corrosive juices empty through the pylorus into the duodenum, the second chamber in man's digestive tract, and start eating through part of that. Though duodenal ulcers never lead to cancer, some types of stomach ulcers are associated with cancer.

Stomach surgery has developed in a broken-gaited fashion, with surgeons periodically going back to and modifying old techniques. Physicians realized in the 1880s that man can get along, after a fashion, with only a remnant of his stomach. German-born Surgeon Theodor Billroth then decided it was possible to cut out the lower stomach and pylorus and join what was left of the stomach to the duodenum (see top diagram). After this "subtotal gastrectomy," or "Billroth I," came a still more daring invention, "hemigastrectomy," or "Billroth II": cutting out about half of the stomach and hitching up what was left to the small bowel, leaving the duodenum dead-ended and dangling (second diagram).

After 1930, these and variant operations were widely used for ulcers. It mattered not that the ulcer might be in the duodenum: the part to cut out, the doctors reasoned, was in the stomach, where the digestive juices were being overproduced. Over the years, doctors concluded that this part was high up in the stomach. Some surgeons went on cutting out not only 50% but 75% to 80% of the stomach. "This," complains Boston's famed Surgeon Francis D. Moore (TIME cover, May 3), "is not only crippling but wanting in elegance of rationale."

Despite such criticism, drastic operations did much good for some patients. The trouble was, no one could tell in advance which patients would die during or soon after the operation, which would develop ulcers again, or which would have a "poor nutritional result" because their reduced stomach dumped undigested food into their small bowels within five or ten minutes after meals instead of a few hours.

Problem of Choice. Not until 1943 was a more elegant and rational attack on ulcers adopted. Since the stomach-wall cells are activated by the vagus nerves (which explains why stress or emotional upsets can trigger the ulcer process), Chicago's Dr. Lester R. Dragstedt figured that cutting the vagus nerves would cut down the acid output. His operation, "vagotomy," is not as simple as it sounds: surgeons often have difficulty finding and cutting all the nerve fibers in the bunch. And by itself, vagotomy is not consistently effective. So vagotomy has been combined with hemigastrectomy (second diagram), and also with the older operation of gastroenterostomy (third diagram), in which nothing is cut out but the stomach is opened directly into the small bowel.

The latest advance in ulcer surgery is still simpler, less mutilating, and therefore "more elegant" by Dr. Moore's definition. This consists of "pyloroplasty," or widening the gate valve between stomach and duodenum by slitting its muscular ring, or "sphincter" (fourth diagram). The tissue is stretched, then the slit is closed at right angles. Such operations (there are several variants) had been around since 1886, but not until 1947 did Dr. Joseph Weinberg of the Long Beach (Calif.) VA Hospital try the promising combination of vagotomy and pyloroplasty. A vagotomy by itself tends to make the stomach flaccid so that it does not empty fast enough; opening its outlet comes close to restoring nature's timing. This approach appeals to such surgeons as Dr. Moore because it is the least mutilating of the available approaches, and a more drastic operation can still be done later if necessary.

But opinion is not unanimous, even in Boston. Dr. Marshall K. Bartlett of Massachusetts General Hospital told the Boston Surgical Society that with several satisfactory operations available, the surgeon's biggest problem is to choose the right one for each patient. He compared the various operations by their results in terms of death rate, recurrence rate and prevalence of the distressing "dumping syndrome." Dr. Bartlett's most definite conclusion was that old-fashioned subtotal gastrectomy carries too great a risk to be considered for most patients, though it may still be the best in special cases.

Dr. Bartlett pays more attention than many other experts to the antrum, the lower part of the stomach's rear wall, which partly controls the output of acids. But the antrum also seems to ex ert a balancing effect, and Dr. Bartlett's M.G.H. team has had good results from a vagotomy combined with removal of about half the stomach but leaving a small part of the antrum intact.

At New York's Downstate Medical Center, Dr. John Madden reviewed the cases of 554 patients who have had various operations or combinations of them at St. Clare's Hospital, and reached a surprising conclusion: the best operation for most patients is "antrectomy" --removal of 35% to 40% of the stomach and hooking the remainder to the duodenum. Dr. Madden dismissed vagotomy alone as unsatisfactory, and gave the Weinberg operation a low rating because too often it fails to effect a cure.

Proponents of the Weinberg technique retort that Dr. Weinberg has had a death rate of only one-half of 1% among 1,129 patients since 1947. Thus, they say, even if the cure rate for a first operation is a few percentage points lower than w:th more drastic surgery, this is more than compensated for by the lower death rate.

Something Better. If the surgeons' arguments are not ended, neither are their ingenious efforts to find better ulcer treatments. Dr. Weinberg is still improving his own technique; he now uses only a single row of stitches to close the slit in the pylorus, reducing the risk of a later shutdown. Other surgeons are combining the Weinberg method with the tying-off of blood vessels, especially for bleeding ulcers. Minnesota's Surgeon Owen H. Wangensteen is trying to make fellow surgeons abandon the knife for nearly all ulcer patients and freeze the stomach instead, a procedure that is hotly debated (TIME, Nov. 8).

The most that can be said so far of any surgery for ulcers is what modest Dr. Weinberg says of his own technique: "It will have to do until we discover something better."

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