The scarring around a patient's duodenal ulcer sometimes obstructs his pylorus, especially if he does not have his earlier ulcer symptoms treated. He may come to you saying that he has been vomiting for days or weeks. He may only vomit once a day, or he may say that he vomits ''everything he eats''. His vomit may contain food that he ate days before. Or, he may not actually vomit, but merely feel abnormally full and bloated after only small amounts of food. He may have eructations, and he may have taught himself to vomit to relieve his symptoms. He loses weight. Continued vomiting depletes his extracellular fluid, and causes hypoclhoraemic alkalosis, and hypokalaemia; eventually he becomes dehydrated and oliguric.
Occasionally, he may improve with a few days of conservative treatment, so that he is able to eat without feeling nauseated. If he does, don't press him to let you operate. He is unlikely to improve permanently. But if he has been vomiting for many days, and is starved and dehydrated with a huge dilated stomach, operate as soon as you have corrected his fluid and electrolyte deficit.
When you operate, do a vagotomy and a gastrojejunostomy, which is a side-to-side anastomosis between the antrum of his stomach and his jejunum. This will be easier than doing a pyloroplasty (11.4) when his duodenum is very scarred, as it usually is in the developing world. In India and Africa a gastroenterostomy may be better than a pyloroplasty, even if his duodenum is not much scarred at the time of surgery, because it may scar later. A retrocolic gastroenterostomy is better than an antecolic one, because the loop of jejunum to be brought up to the stomach is shorter, and there is no abnormal hole in his mesentery, through which loops of gut can herniate and twist. Make the stoma vertical so that it drains more easily.
His duodenal ulcer may be anterior or posterior. The other important cause of stenosis of his distal stomach is carcinoma, see Section 32.25.
PYLORIC STENOSIS EXAMINATION. Lay the patient down and look for visible peristalsis, as his stomach struggles to empty itself through his narrowed pylorus. Look for slow waves moving from his left hypochondrium towards and beyond his umbilicus. Rock him from side to side. You may hear hear a succussion splash. You may also hear it if you depress his epigastrium sharply with your hand (a splash may be normal after a large meal).
WASHOUTS will empty his stomach, remove debris, and rest it. With luck, his inflamed and oedematous pylorus will open up. Washouts, as in Fig. 25-11, will also reduce the risk of postoperative infection.
Find a funnel, a large (36 Ch, about 1 cm diameter) stomach tube or a catheter, and a longer piece of rubber connecting tube the same size. Lay him supine with his head supported over the end of the bed, as in Fig. 25-11. Pass the well-lubricated stomach tube through his mouth and encourage him to swallow it. Connect the stomach tube via the other tube to the funnel. Hold up the funnel and pour in 500 ml of water. Before the last drop has left the funnel, lower it over a bucket (to prevent air entering). His stomach contents will run out. Repeat the process, this time using a litre of water. Go on doing this until the fluid returns clear. Finally, leave 500 ml inside him.
Repeat this daily, for 3 days, or until he is fit for surgery, whichever is later. Don't wash him out on the day of the operation.
FOOD. Give him any convenient fluid diet, such as milk with added sugar, but don't give him anything to eat.
X-RAYS are useful if the diagnosis is in doubt. Take an erect abdominal film, and look for a large fluid level in his left upper quadrant. A drink of barium will produce a mottled shadow showing that his gastric outline is much enlarged. Little or no barium passes his pylorus. Don't give him a large quantity, because it may be difficult to wash out.
NON-OPERATIVE TREATMENT [s7]FOR PYLORIC STENOSIS REHYDRATION, may be necessary over several days to restore his extracellular fluid volume. Use the methods in A 15.3. Give him 0.9% saline or Ringer's lactate. If necessary, correct his potassium loss with up to 80 mmol of potassium daily, or use Darrow's solution (K 34 mmol/litre). Be guided by the volume and specific gravity of his urine output.
GASTROENTEROSTOMY [s7]FOR PYLORIC STENOSIS INDICATIONS. (1) Pyloric obstruction causing dehydration and weight loss, or other long-standing obstructive symptoms as described above. (2) Duodenal ulceration with sufficient scarring to contraindicate pyloroplasty; combine it with a truncal vagotomy. (3) As a palliative procedure for stenosis caused by an antral carcinoma. (4) For a duodenal ulcer in a woman of over 60.
ANAESTHESIA. Give him a general anaesthetic with a muscle relaxant (A 14.3).
POSITION. Lay him supine with his upper abdomen pushed forward by ''breaking the table', or by putting a pillow under his back.
INCISION. Make an upper midline incision, or, if he has well developed muscles, a right upper paramedian one.
If you find a large thick walled stomach, the diagnosis of pyloric stenosis is confirmed. Ask your assistant to retract his liver upwards with a deep retractor, and to draw his stomach downwards at the same time.
Is the obstruction malignant? First, try to make sure that he has not got a carcinoma of his pylorus. If he has lumps and nodules, enlarged hard lymph nodes, and perhaps an ulcer crater, just proximal to his pylorus, suspect a carcinoma. Biopsy a node. He has probably got a chronic duodenal ulcer if he has: (1) Puckered scarring on the front of the first part of his duodenum, perhaps with adhesions to surrounding structures. (2) An indentation on the posterior wall of his stomach extending into his pancreas to which it is fixed. Carcinoma does not attack the first part of the duodenum, so that lesions there are almost certainly benign.
If you are not sure what is obstructing the outlet of his stomach, do a gastroenterostomy and biopsy a regional node. Don't biopsy his stomach itself unless you intend to resect it. If you find a carcinoma, you can refer him for definitive surgery later[md]if the tumour is resectable (no spread to his liver or to nodes beyond those on the greater and lesser curves of his stomach). See Section 32.25.
Fig. 11-6 GASTROENTEROSTOMY. A, reflecting the patient's colon upwards, so as to expose the back of his stomach. Incising his mesentery. B, bringing his stomach and jejumum together through his transverse mesocolon. Notice the position of his middle colic vessels. C, applying a non-crushing clamp to his jejunum. D, stay sutures and the posterior seromuscular (Lembert) layer. E, tying the vessels in the muscle of his stomach. F, opening his jejunum, G, the posterior all[nd]coats layer. H, the second Connell inverting stitch. I, the anterior layer. J, the final Connell stitch. K, the anterior seromuscular layer of sutures. L, testing the stoma.
METHOD FOR GASTROENTEROSTOMY. Start by doing a vagotomy (11.4), if this is indicated.
Ask your assistant to lift up the patients's transverse colon with both his hands, so as to expose the posterior layer of his transverse mesocolon. Find his middle colic vessels. You will see the posterior wall of his stomach through his mesocolon (A, in Fig. 11-6). If he is thin, you will see it easily; if he is fat, it will be easier to feel.
Apply Babcock's forceps to the posterior aspect of his stomach about 6 cm apart (B). Take up his mesocolon in the bite in an area well to the left of his middle colic vesels, leaving enough rooom for his jejunum to be brought alongside. Using the Babcock's as markers, push his stomach through his mesocolon from above.
CAUTION ! Make sure that the Babcock forceps are not too near any lesion he may have on the greater curve of his stomach.
Find his upper jejunum and apply Babcock forceps to that. The first should be about 8 cm from his duodeno-jejunal flexure, and the second about 6 cm distal to that (B). Apply a non- crushing clamp as shown (C), to hold two-thirds of the width of the gut.
Insert stay sutures through the seromuscular coats of his stomach and jejunum at each end, going through his mesocolon. His stomach wall is likely to be thick, perhaps very thick, if his pyloric stenosis is long-standing.
Continue the layer of interrupted seromuscular sutures using 2/0 multifilament silk (D).
Carefully incise the muscle of his stomach. This will reveal some blood vessels. Doubly tie these with 2/0 silk or smaller (E), and divide them between the ties.
Open his stomach by cutting its mucosa, for about 3 fingers length (5 cm). Then, open his jejunum for an equal length, half way between the suture line and the clamp (F).
Use 2/0 atraumatic catgut for the ''all coats' layer (G), starting at one end with an inverting Connell stitch, in the same way as for a side-to-side anastomosis. See Fig. 9-12.
CAUTION ! (1) Be sure to include all layers of his stomach wall in the anastomosis. If it is hypertrophied, the cut edges of its mucosa will curl away. If you fail to include them in your sutures, they may bleed, or the suture line may leak. (2) Take care not to rupture his spleen, or his gastrosplenic vessels by pulling on his stomach too much[md]make sure you have adequate exposure.
Continue the suture along the posterior layer of the anastomosis, and do an inverting suture at the end (H). Then do the anterior layer (I), using a simple over-and-over suture and ending with a Connell inverting stitch (J). Tie the ends of the suture together and and cut them 0.5 cm distal to the knot.
Insert a layer of interrupted sutures through the seromuscular coats of his stomach and jejunum, picking up his mesocolon with them (K). Remove the clamp, and feel the size of the stoma: it should admit 2 or 3 fingers (L). Replace his transverse colon in his abdomen.
DIFFICULTIES [s7]WITH A GASTROENTEROSTOMY If his PEPTIC ULCER SYMPTOMS recur, you have not been successful in cutting all the branches of his vagus. An incomplete vagotomy is the main reason why this operation fails. If possible, give him a course of cimetidine, 200 mg three times a day and 400 mg at night for 4 weeks. If not try medical treatment with antacids (11.1). If his pain is not relieved, or he bleeds sigificantly, refer him.
If you CONTINUE TO ASPIRATE A LITRE OR MORE OF FLUID after the operation, the stoma is not functioning, or he has paralytic ileus. Bowel sounds and the absence of abdominal distension will exclude the latter. The stoma will be less likely to obstruct, if you make it big enough to take three fingers. It may remain obstructed for 2 weeks. Continue nasogastric suction, unless there is an indication to reoperate (10.13), and give him parenteral fluids. His stoma is almost certain to open eventually.
If, some time after the operation, he STARTS TO VOMIT BILE, reassure him. Bile and pancreatic juice are accumulating in the afferent loop, and when they are suddenly released into his stomach, he vomits. His symptoms will probably improve with time. If they don't improve in 2 years, consider referring him for a revision procedure.