When the symptoms continue or, as is much more frequently the case, when they return after the patient resumes an ordinary diet, the case should be pronounced to be one in which an operation is necessary. The danger of complications, as hemorrhage and perforation, and the liability to a life of chronic invalidism, or to the termination of the affection in cancer being pointed out, the patient usually consents to place himself in the hands of the surgeon.
Operations for Gastric Ulcer.—The exact nature of the operative pro cedure cannot be decided upon till the stomach is exposed and the actual condition in each case is determined, but the growing tendency amongst all surgeons is to the routine of doing a posterior (no loop) gastro-jejun ostomy by von Hacker's method, in which a vertical application of the jejunum to the stomach is effected as described under Gastric Dilatation. Finney's gastro-duodenostomy is less satisfactory. Watson Cheyne, believing in the tendency to spontaneous cure if the stomach can be secured rest, advocates Gastrostomy and feeding by a tube passed through the pylorus.
If the ulcer be recognisable as such it should always be excised. Ulcers near the cardia are the most difficult owing to their inaccessibility, but fortunately they are not very common in this situation. In all cases of excision the operation is completed by a posterior gastro-enterostomy, otherwise the ulcer will in the great majority of cases recur.
Mitchell has pointed out the importance of partially occluding the duodenal exit in order to secure patency of the artificial one; this he accomplishes by a purse-string suture of the pylorus, the needle passing deeply into the substance of the muscle. The mortality of gastro-enter ostomy for chronic ulcer is now reduced below r per cent.
The formation of a peptic ulcer in the duodenum or jejunum after gastro-enterostomy is becoming a rare event since the introduction of the perfected methods above described in the posterior no-loop operation, as insisted upon by Moynihan, Mitchell and others, with partial or com plete obliteration of the pyloric orifice so as to keep the new route patent.
contraction of the stomach, if found present, requires radical operative methods. Gastroplasty, or the division of the stricture between the two sacs, is not a successful procedure, as recurrence is liable to follow. Cylindrical Gastrectomv, in which end-to-end union is effected, meets many cases.
Gastro-enterostomy often is followed by recurrence. Monprofit and Clement have devised anastomosis operations by means of which each pouch may he drained separately into the jejunum. The best procedure is ; this consists in making an anastomosis or direct connection between the two pouches by folding over the pyloric pouch upon the gastric one, and then performing a posterior gastro-enterostomy in order to drain both.
Operation for if possible should never be attempted when the patient is in au exhausted anaemic condition; the hmmorrhage usually can be effectually controlled by medical treatment as detailed upon p. 32 r.
In recurring severe haemorrhages (gastrostaxis or gastrorrhagia), as the next attack may prove fatal, a gastro-enterostomy should be performed. When this is decided upon no interference with the bleeding ulcer need be thought of; as soon as the collapse of the stomach walls has occurred after the operation, if bleeding has been active it stops, and never returns.
Many, surgeons maintain that, once the diagnosis becomes established, surgical measures should not be delayed, but the recent tendency to modify this is becoming marked, and the opinion is that the rest and dietetic treatment so often successful in gastric ulcer should have a trial before the knife is resorted to.