Symposium on Peptic Ulcer Disease

Obstructing Duodenal Ulcer Robert E. Hermann, M.D. *

Gastric outlet obstruction, secondary to pyloric stenosis, in my experience, is the second most common indication for surgery in duodenal ulcer disease. According to several reports, the incidence of obstruction as an indication for surgery ranges from 11 to 30 per cent, depending on the patient population and on the incidence of elective versus emergency operations. 4 • 8. 10. 12 In almost all series of cases, intractability of the disease to medical management is the most frequent indication for surgery in from 45 to 60 per cent of patients. Hemorrhage, the other frequent reason for surgery, is the principal indication in from 20 to 30 per cent of patients. In many patients a combination of indications may exist: a long history of episodic or recurrent ulcer pain, one or two episodes of melena, and the development of incomplete gastric emptying and nausea with occasional vomiting, making the indentification of any single indication for surgery difficult or inexact.

PATHOGENESIS Gastric outlet obstruction occurs during the course of duodenal ulcer disease because of recurrent episodes of ulceration and inflammation in the pyloric channel or duodenal bulb, followed by healing of the ulcer and the deposition of scar tissue. Over a period of 10 or 15 years, with repeated episodes of duodenal ulceration, healing, and fibrosis, the pyloric channel or duodenal bulb becomes relatively scarred and stenotic with increasing gastric outlet obstruction. An active ulcer crater is frequently, but not always, present. In most patients, the gastric outlet obstruction is incomplete and some food, gastric juice, or ingested barium by roentgenography can be demonstrated to leave the stomach slowly. In a few patients, however, the gastric outlet obstruction may become complete. In some patients, because of persistent or chronic gastric stasis, gastric ulceration may develop secondary to the duodenal ulcer and may be the indication for operation. *Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio

Surgical Clinics of North America- VoL 56, No.6, December 1976

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SYMPTOMS Obstructing duodenal ulcers do not always give the classic symptoms of obstruction with nausea and vomiting, upper abdominal distention, and absence of the passage of gas or stool or rectum. In my experience, the most frequent single symptom has been increased ulcer pain with poor response to medical control due to incomplete gastric emptying. Nausea, distention, and a feeling of constant fullness or bloating are almost always a part of the symptom complex, but the ulcer pain may well overshadow these symptoms. Patients whose ulcers, in the past, have always been amenable to medical control with the use of bland foods or antacids now find that these foods or antacids no longer bring relief. With increasing pyloric stenosis, a pool of gastric juice and food remains in the antrum with continuing antral stimulation, antral distention, and stimulation to the secretion of more acid. With persistent gastric stasis and antral stimulation, the increased amounts of acid secreted frequently cause further irritation of the duodenum with active ulceration and edema on top of the previous pyloric scarring, further increasing the obstruction. In some patients, a new gastric ulcer may occur. The patient frequently induces vomiting to gain relief from the feeling of fullness and pain. On admission to the hospital, after passage of a nasogastric tube and decompression of the stomach, striking relief of the pain may be achieved. Within 1 or 2 days of decompression of the stomach, gastric distention is usually relieved and gastric tone returns.

Figures 1 through 5 represent upper gastrointestinal roentgenographic series. Figure 1'. Oblique view above shows pyloric stenosis and no visualization of descending duodenum.

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DIAGNOSTIC STUDIES Roentgenographic studies are extremely helpful in identifying the presence and site of gastric outlet obstruction or the incomplete gastric emptying. Lateral or oblique views of the pyloric channel and duodenum are essential to visualize this area and to determine the degree of pyloric stenosis (Figs. 1 and 2). In the absence of lateral or oblique views, on the standard anterior-posterior views the distended antrum often hides the pyloric region and duodenal bulb (Fig. 3). The stomach is dilated, frequently twice its normal size, gastric rugal folds are hypertrophied and thickened, and delayed gastric emptying is noted for a period of 6 or 8 hours following ingestion of a barium meal (Fig. 4). In some patients, as noted above, a gastric ulcer may be seen (Fig. 5). Gastroscopic examination will confirm the marked scanning of the pyloric channel. Usually the gastroscope cannot be passed out of the stomach into the duodenum. Retained food or secretions may be seen in the stomach, and the gastric mucosa is frequently hypertrophied and edematous.

*

Figure 2. Oblique view shows postbulbar narrowing and stenosis with an active postbulbar ulcer crater.

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*

Figure 3. Anteroposterior view shows a dilated stomach with thickened gastric folds. The dilated antrum hides the area of stenosis.

Figure 4. This view shows a dilated stomach with thickened gastric rugal folds, and delayed gastric emptying.

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Figure 5. View of a lesser curvature gastric ulcer in a patient with duodenal deformity and persistent gastric stasis.

CLINICAL MATERIAL In a personal series of 309 patients operated upon for duodenal ulcer disease between 1962 and 1975, approximately 83 patients (27 per cent) had evidence of an obstructing duodenal ulcer as the principal indication for surgery (Table 1). In this group of patients, duodenal ulcer disease was present symptomatically from 48 months to 45 years, with a mean duration of symptoms of approximately 11 years. All patients had medical treatment intermittently or sporadically for the relief of symptoms through the years. The symptoms of pyloric channel or gastric outlet obstruction had been present from 1 to 6 months prior to operation. Six patients had a previous episode of gastric obstruction, relieved by nasogastric suction and intensive medical therapy. Twenty-two patients had a history of bleeding, although none of the patients had had a serious or massive hemorrhage. Two patients had a previously perforated duodenal ulcer; both had had a plication procedure. The operations performed in this group of patients are listed in

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Table 1. Indications for Surgery in Patients with Duodenal Ulcer, 1962-1975 NO. OF PATIENTS

PER CENT

Intractability Obstruction Bleeding Perforation

158 83 49 19

51 27 16 6

TOTAL

309

100

Table 2; they include vagotomy and pyloroplastomy, vagotomy and gastrojejunostomy, vagotomy and gastroduodenostomy, vagotomy and antrectomy, and subtotal gastrectomy. The operations were elective in all patients; no operative mortality was recorded.

RESULTS The results of operation were graded during follow-up evaluation by mailed questionnaires and by personal interviews from A through D, using the classification designed by Hoerr.7 Patients graded A or Bare considered excellent or good results; patients graded C are poor results, and patients graded D have symptoms of recurrent ulcer. The criteria for grading are: A. No gastrointestinal symptoms. B. Minor gastrointestinal symptoms; no evidence of a recurrent ulcer. The patient is satisfied with the results and is pursuing his usual occupation. C. The patient is dissatisfied with the function of his gastrointestinal tract, but there is no evidence of a recurrent ulcer. D. A proved or probable ulcer has recurred, or the patient is disabled from other gastrointestinal symptoms.

Of the 83 patients with obstructing duodenal ulcers, a group of 57 patients has now been followed from 2 to 13 years with a mean duration of follow-up 7 years; 53 per cent are considered an A result, 42 per cent are considered a B result, none are considered a C result, and 5 per cent (3 patients) are considered a D result, all because of recurrent ulcer

Table 2. Operations for Obstructing Duodenal Ulcer, 1962-1975 OPERATION

Vagotomy and pyloroplasty Vagotomy and gastrojejunostomy Vagotomy and gastroduodenostomy Vagotomy and antral resection Subtotal gastrectomy (without vagotomy) TOTAL

NO. OF PATIENTS

PER CENT

62 12 5 3 1

75 14.5 6 3.5 1

83

100

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symptoms. In two of the three patients, medical treatment alleviated all symptoms. Only one patient (2 per cent) required another operation, a subtotal gastric resection. None of the patients has had disabling gastrointestinal symptoms such as severe diarrhea, dumping, or postprandial distress.

DISCUSSION Patients with obstructing duodenal ulcers usually have a long his- . tory of ulcer disease, an average of 11 years in our experience. During these years of the disease, medical control of ulcer symptoms has generally been effective, at least effective enough that surgery has never been advised or, if advised, the patient has decided not to have an operation. Thus, medical symptoms have not been incapacitating, and most patients have lived quite well with their symptoms until the complication of pyloric stenosis or gastric outlet obstruction developed. It would appear, with mild pain or other symptoms of duodenal ulcer disease, that when surgical intervention becomes necessary because of the development of obstructive symptoms, the surgical procedure might be a conservative one, one that would relieve the obstruction as well as decrease gastric acidity. In addition the operation should be safe, since in almost all patients with obstructing duodenal ulcer the operation can be elective. I favor vagotomy and a drainage procedure for most patients with obstructing duodenal ulcer because it is the safest effective ulcer operation. Vagotomy and antrectomy is selected for young patients with severe ulcer symptoms or a history of multiple complications of the disease. In the past, there was controversy as to whether a vagotomy should be performed for patients with obstructing duodenal ulcers. Bergin and Jordan,! and Kraft, Fry, and DeWeese,9 in the late 1950s and early 1960s, cautioned against the use of vagotomy on the chronically obstructed stomach, reporting an increased incidence of postvagotomy gastric atony in these patients. Other surgeons, including myself, have not found postvagotomy gastric atony to be a problem in patients with obstruction. In fact, many surgeons have found their best results with vagotomy and drainage for chronic duodenal ulcer disease in patients with gastric obstruction as an indication for the operation. Hoerr and Ward,7 reviewing a 17-year experience with three operations for duodenal ulcer, all of which included truncal vagotomy (vagotomy-gastrojejunostomy, vagotomy-hemigastrectomy and vagotomy-pyloroplasty) found that all three operations when utilized for obstruction gave excellent results with low incidences of recurrent ulceration. Second operative procedures for recurrent ulcer were necessary in less than 4 per cent of patients regardless of the operative procedure performed. Vagotomy and gastrojejunostomy appeared to have the best results when utilized for patients with obstructing duodenal ulcers. Similar excellent or good results have been obtained by Davis and Williams2 with vagotomy and pyloroplasty; by Ellis, Starer, Venables, and Wares using vagotomy and gastrojejunostomy; and by

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DeMatteis and Hermann3 who combined vagotomy with a comparison of four types of drainage procedures. An important aspect of the surgical management of obstructing duodenal ulcer is to obtain adequate drainage of the stomach, along with the vagotomy, at the time of the operative procedure. In my opinion, this can best be achieved by a Finney pyloroplasty or by an adequate gastrojejunostomy. A gastroduodenostomy (Jaboulay procedure) may provide excellent decompression of the chronically obstructed stomach, but a Heineke-Mikulicz pyloroplasty, in my opinion, is usually not as effective because the duodenal bulb or pyloric channel is too scarred. Vagotomyand antrectomy or hemigastrectomy, although an extemely effective ulcer operation, has a higher operative mortality (2 to 3 per cent), a greater incidence of postoperative dumping and diarrhea, and may not be necessary for any but a few patients with obstructing ulcers. 6 ,11 Because of the degree of scarring in the pyloric channel in most patients with obstructing ulcers, I doubt that proximal gastric vagotomy and dilatation of the pylorus would be advisable. Because of the safety of the procedure and its effectiveness in 95 per cent of patients, I continue to prefer vagotomy and Finney pyloroplasty or vagotomy and gastrojejunostomy for most patients with obstructing duodenal ulcers. In a young patient with a history of multiple complications of duodenal ulcer, now with symptoms of gastric outlet obstruction, I would choose vagotomy and antrectomy as the most effective ulcer operation, one which might be necessary in selected patients with a history of muliple ulcer problems.

SUMMARY The incidence, pathogenesis, symptoms, roentgenographic, and endoscopic findings of patients with gastric outlet obstructi

Obstructing duodenal ulcer.

Symposium on Peptic Ulcer Disease Obstructing Duodenal Ulcer Robert E. Hermann, M.D. * Gastric outlet obstruction, secondary to pyloric stenosis, in...
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