Surgery: How Much of the Stomach Should Be Cut Out?

Should Be Cut Out?

According to medical statistics, some 12 million Americans have, or have had, ulcers of the stomach or duodenum.

Every day, ulcers claim 4,000 new victims; every year, surgeons put about 150,000 ulcer patients on the operating table. There are half a dozen major types of surgery for ulcers, plus a dozen minor variants. Some of them are al most a century old, but physicians and surgeons still cannot concur on which type of operation is the best, or even which is best for any particular patient.

Last month specialists in Boston and New York reviewed the whole field in an effort to outline areas of agreement. They succeeded in illuminating the variety of argument.

Wanting in Elegance. Nobody knows the root cause of ulcers in the digestive tract, but what happens after the process gets started is fairly clear. Countless cells in the wall of the stomach secrete chemicals, such as gastrin, and hydrochloric acid. These are designed by nature for the digestion of food. But if for any reason—physical or emotional —the stomach cells churn out digestive juices when there is no food for them to work on, they may start digesting a spot on the wall of the stomach itself. The result is a gastric ulcer. More often, the corrosive juices empty through the pylorus into the duodenum, the second chamber in man's digestive tract, and start eating through part of that. Though duodenal ulcers never lead to cancer, some types of stomach ulcers are associated with cancer.

Stomach surgery has developed in a broken-gaited fashion, with surgeons periodically going back to and modifying old techniques. Physicians realized in the 1880s that man can get along, after a fashion, with only a remnant of his stomach. German-born Surgeon Theodor Billroth then decided it was possible to cut out the lower stomach and pylorus and join what was left of the stomach to the duodenum (see top diagram). After this "subtotal gastrectomy," or "Billroth I," came a still more daring invention, "hemigastrectomy," or "Billroth II": cutting out about half of the stomach and hitching up what was left to the small bowel, leaving the duodenum dead-ended and dangling (second diagram).

After 1930, these and variant operations were widely used for ulcers. It mattered not that the ulcer might be in the duodenum: the part to cut out, the doctors reasoned, was in the stomach, where the digestive juices were being overproduced. Over the years, doctors concluded that this part was high up in the stomach. Some surgeons went on cutting out not only 50% but 75% to 80% of the stomach. "This," complains Boston's famed Surgeon Francis D. Moore (TIME cover, May 3), "is not only crippling but wanting in elegance of rationale."

Despite such criticism, drastic operations did much good for some patients. The trouble was, no one could tell in advance which patients would die during or soon after the operation, which would develop ulcers again, or which would have a "poor nutritional result" because their reduced stomach dumped undigested food into their small bowels within five or ten minutes after meals instead of a few hours.