Sectional view of the result when two folds are turned in.
Fig. 546
Fig. 547
Gastroplication. (Brandt.)
Sectional view of the result.
The rationale of making an anastomotic opening between the stomach and the upper end of the bowel is simply this: that thereby the stomach is given a degree of physiological rest to which it has long been a stranger, and that food may pass easily from the stomach into the upper bowel without irritating or aggravating the ulcerated portion, which is usually at the pyloric end. It should be understood, then, that gastro-enterostomy, done for this purpose, is simply a means of carrying out the universally applicable canon of physiological rest for diseased organs or surfaces. The operation of making this anastomosis will be described below.
Pylorectomy and Gastrectomy.
—A complete removal of the pyloric end of the stomach is usually referred to as pylorectomy, while still more extensive extirpation of portions of the stomach proper are spoken of as gastrectomies. In a few instances it has been possible to practically remove the entire stomach, this having first been done by Schlatter. Such an operation would be spoken of as total gastrectomy. These operations are done almost exclusively for removal of areas involved in cancerous growth. Obviously the more extensive the growth the greater the amount of stomach which should be removed. For some reason as yet unknown cancer of the stomach rarely transgresses the pyloric ring, and thus the first part of the duodenum usually escapes involvement, even though the stomach be extensively diseased. All these operations, therefore, include simply the removal of a part terminating with the pyloric ring proper. It is seldom necessary to take away any of the duodenum. Removal of the pylorus may be also applicable in certain cases of benign strictures, where the mere plastic operations would seem insufficient, as well as in the cases of ulcers encroaching upon the pyloric ring itself.
For all of these operations the stomach is exposed through a median incision, or, if a tumor presents distinctly upon the right side, the incision may be made even far to the right and near the semilunar line. Through an opening sufficiently liberal the stomach and the movable part of the duodenum are withdrawn and carefully examined. When the pylorus is so fastened by dense adhesions within the abdomen that it cannot be withdrawn it is best to abstain from this particular procedure, as the mechanical difficulties too greatly enhance its dangers. Suitable clamps, whose blades are protected with soft rubber, are essential in order that the duodenum may be clamped beyond the line of its division, and that the stomach as well may be fixed between their blades, for the double purpose of controlling hemorrhage and preventing escape of contents. The omentum along the involved part of the stomach should then be carefully tied off, in a series of loops, before its vessels are cut, and one should take great pains to hunt out enlarged lymph nodes and include them in the area to be removed, or else make a separate incision for those that cannot be thus extirpated. To leave lymph nodes which are perceptibly involved in the cancerous process is to invite the speediest possible return of the disease, even though the operation should be successful. The upper and lower borders of the stomach being thus freed, the surgeon is then at liberty to cut away all the diseased portion, going at least an inch beyond the apparent limit of the disease. There will result from any such operation two divided ends of the alimentary canal, i. e., one, that of the divided stomach, much larger than the other, which is the upper end of the duodenum.