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Problem of Choice. Not until 1943 was a more elegant and rational attack on ulcers adopted. Since the stomach-wall cells are activated by the vagus nerves (which explains why stress or emotional upsets can trigger the ulcer process), Chicago's Dr. Lester R. Dragstedt figured that cutting the vagus nerves would cut down the acid output. His operation, "vagotomy," is not as simple as it sounds: surgeons often have difficulty finding and cutting all the nerve fibers in the bunch. And by itself, vagotomy is not consistently effective. So vagotomy has been combined with hemigastrectomy (second diagram), and also with the older operation of gastroenterostomy (third diagram), in which nothing is cut out but the stomach is opened directly into the small bowel.
The latest advance in ulcer surgery is still simpler, less mutilating, and therefore "more elegant" by Dr. Moore's definition. This consists of "pyloroplasty," or widening the gate valve between stomach and duodenum by slitting its muscular ring, or "sphincter" (fourth diagram). The tissue is stretched, then the slit is closed at right angles. Such operations (there are several variants) had been around since 1886, but not until 1947 did Dr. Joseph Weinberg of the Long Beach (Calif.) VA Hospital try the promising combination of vagotomy and pyloroplasty. A vagotomy by itself tends to make the stomach flaccid so that it does not empty fast enough; opening its outlet comes close to restoring nature's timing. This approach appeals to such surgeons as Dr. Moore because it is the least mutilating of the available approaches, and a more drastic operation can still be done later if necessary.
But opinion is not unanimous, even in Boston. Dr. Marshall K. Bartlett of Massachusetts General Hospital told the Boston Surgical Society that with several satisfactory operations available, the surgeon's biggest problem is to choose the right one for each patient. He compared the various operations by their results in terms of death rate, recurrence rate and prevalence of the distressing "dumping syndrome." Dr. Bartlett's most definite conclusion was that old-fashioned subtotal gastrectomy carries too great a risk to be considered for most patients, though it may still be the best in special cases.
Dr. Bartlett pays more attention than many other experts to the antrum, the lower part of the stomach's rear wall, which partly controls the output of acids. But the antrum also seems to ex ert a balancing effect, and Dr. Bartlett's M.G.H. team has had good results from a vagotomy combined with removal of about half the stomach but leaving a small part of the antrum intact.
At New York's Downstate Medical Center, Dr. John Madden reviewed the cases of 554 patients who have had various operations or combinations of them at St. Clare's Hospital, and reached a surprising conclusion: the best operation for most patients is "antrectomy" —removal of 35% to 40% of the stomach and hooking the remainder to the duodenum. Dr. Madden dismissed vagotomy alone as unsatisfactory, and gave the Weinberg operation a low rating because too often it fails to effect a cure.