Surgery of peptic ulceration and its complications.

Stomal Ulceration Stomal ulceration may follow anastomosis of the stomach to any other part of the alimentary canal. I have indicated in my first lecture that by I954, stomal ulceration had followed in over 50 per cent. of the cases in which I had carried out a gastrojejunostomy for duodenal ulcer in I943. In such cases at the second operation, the duodenal ulcer, although often reported as active by the radiologist, is almost invariably healed and inactive, though sometimes stenosed. The only occasions on which I have found activity in the duodenal ulcer was when there was a gastro-colic fistula or stenosis of the gastro-jejunal stoma. The jejunal ulcer is usually on the jejunal side of the stoma, near the efferent loop, but is occasionally quite apart from the stoma and sometimes multiple. If an ulcer is seen on the gastric side and is not on the stoma, it almost invariably means that the patient has had a gastro-jejunostomy for, or in the presence of, a gastric ulcer. In such cases the jejunum is usually intact, but the gastric ulcer may remain active. I have on several occasions seen both an active gastric ulcer and a healthy gastrojejunostomy in the same field at gastroscopy. After gastrectomy for gastric ulcer, stomal ulceration is of the greatest rarity. I had personally performed 690 gastrectomies for gastric ulcer before operating on the first case which subsequently developed a stomal ulcer, and in well over a thousand resected in our clinic, this remains the only known case. It was indeed an unusual one in that the gastric ulcer appeared in the prepyloric region on the greater curve side of the stomach. The patient was a man of 45, who had taken aspirin daily for some years. Although the ulcer almost healed under a medical regime, we felt it wiser to resect it in view of its position, and ulcer symptoms recurred within a year. In the follow-up of 6i i of our gastrectomies for peptic ulcer by Mr. Colin Craig and Dr. Chippendale, there were no recurrent ulcers among the gastric ulcer resections, but five proven and one doubtful stomal ulcer among 244 resections for duodenal ulceration-a recurrent ulcer rate of 2.5 per cent. Here again stomal ulceration following gastric resection is, in my experience, invariably in the jejunum and never in the stomach. Occasionally, post-operative deformities mimic a recurrent gastric ulcer, but I have never failed to disprove its presence by gastroscopy or by subsequent operation. It is interesting to consider why the stomach does not undergo peptic ulceration after gastrectomy, either for gastric or duodenal ulcer. The problem is a difficult one and its solution depends on the causation of ulcer and ulcer pain. I have pointed out previously (Tanner, i95I) that during digestion there is varying intensity in the concentration of acid in different parts of the stomach after a meal, the acidity probably being higher at the upper level of gastric chyme. I believe that prolonged contact with this concentrated level may play some part in the development of ulcer, and that the time when this level comes opposite the ulcer is the time when ulcer pain occurs. After gastrectomy there is a more rapid descent of the top level of gastric chyme. The acid concentration is diminished because there is a diminished volume of gastric juice, and there is more mixing as a result of the constant inflow of biliary and duodenal juices into the gastric remnant. The jejunum, however, is more susceptible to ulceration. Possibly the unbuffered intercibal secretions play an important part in producing jejunal ulceration, which occurs where the acid concentration is greatest, near the efferent loop, and at the site of greatest weakness, the jejunal side of the suture line scar.