Total gastrectomy for carcinoma of the stomach

T HE surgeon is frequentIy confronted with patients suffering from carcinoma of the stomach. These Iesions may be diagnosed quite earIy, particuIarIy those near the pyIorus, since symptoms are IargeIy dependent on the amount of obstruction present. Holmes and Hampton’ have pointed out that any ulceration in the immediate prepyIoric region may be Iooked upon as neopIastic until proved otherwise. The success achieved in this favorabIe group has offset to some extent the mortaIity associated with more extensive resections for growths previousIy Iooked upon as inoperabIe. Parsons2 has found that 20 per cent of patients surviving partiaI gastrectomy for cancer at the Massachusetts Genera1 HospitaI are Iiving and apparentIy free from disease from five to nine and a haIf years after operation. With the advent of better pre-operative preparation, anesthesia, and surgica1 technique, there has been a definite trend to more radica1 surgery in this field. TotaI gastrectomy has been of interest to surgeons since the beginning of gastric surgery and as earIy as 1878 we find reported the experiments carried out in Czerny’s cIinic by Kaiser,3 who found that dogs Iived happiiy and in good heaIth for as Iong as five years after subtotal gastrectomy. This work was of great interest not onIy to the cIinician but to the physioIogist as weI1. There was at this time considerabIe doubt that an anima1 couId Iive without any gastric tissue at aI1. ApparentIy with this went some argument as to exact definition of total gastrectomy : there was some feehng that if a11 the stomach between the cardia and pyIorus were removed, the resuIt might be considered a tota extirpation. FinaIIy, however, the true definition became evident. We are now agreed that onIy where the esophagus above the cardia, and the duodenum beIow the pyIorus have been removed with the intervening stomach, is there a true tota gastrectomy. The first record of this operation on a human being was made by Conner4 in 1884. His’ patient was said to have been moribund at the time and died of shock just after the procedure had been finished. No other reports are avaiIabIe unti1 1897, when SchIatter5 successfuIIy extirpated the entire stomach for cancer in a woman aged 56. He united the jejunum to the esophagus and the patient Iived approximateIy fourteen months after which she died of recurrence of the carcinoma. FolIowing this famous case there was renewed interest in the operation and graduaIIy there have appeared in the Iiterature a good many case reports. Without doubt, many such operations which were carried out, have never been reported. In 1927 and 1929, Finney and Reinhoff6s7 carefuIIy coIIected the subtota1 and tota gastrectomies on record at this time, caIIed attention to the correct definition of the operation, and gave a fuI1 report on the historica data and factors favoring a successfu1 outcome. They reported five tota gastrectomies of their own and coIIected sixty-two additiona cases that they felt to be authentic. They pointed out that a smaI1 remnant of norma stomach at the cardia, to be used in the anastomosis to the jejunum, greatIy Iowered the hazard,