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The noxious antral remnant in treatment of peptic ulcer of the duodenum

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Conclusions

Until some “anti ulcer” medicament, hormone or biologic extract similar to Enterogastrone, Urogastrone or Anthelon is developed and made clinically applicable, the objective of treatment remains diminution of, or elimination of hydrochloric acid from the gastric content.

In Mann-Williamson dogs (where the acid secreting parietal cells are distributed throughout the entire gastric mucosa) stomal ulcer develops after “subtotal” gastrectomy, but does not do so after total (98%) gastrectomy (15).

In man (with the acid secreting cells usually limited to the proximal two-thirds of the stomach) removal of the alkaline secreting distal antrum is therefore unnecessary in an attempt to reduce hydrochloric secretion.

Because of the disadvantages of distal resection, and because of the “pari passu” improvement with more and more proximal resection (shift to the left) it may be that the fundal remnant after subtotal gastrectomy, is more “noxious” than an antral remnant.

Total fundusectomy (proximal partial gastrectomy) with removal of practically all (98%) of acid secreting fundus and body with anastomosis between the cardia and the alkaline secreting antrum would seem to be a logical physiologic improvement in the treatment of peptic ulcer and worthy of a clinical trial in surgical treatment of duodenal ulcer.

Removal of the secreting apparatus, the parietal cells, would permit a disregard of the various indirect (hormonal neural, cerebral, gastric or intestinal) stimuli to hydrochloric acid secretion,retain the advantages of the presently accepted “subtotal” gastrectomy (reduction of hydrochloric acid secretion) whileavoiding its disadvantages (stomal ulcer, the post-gastrectomy or “dumping” syndrome) that sometimes follow the unphysiologic gastrojejunal continuity and loss of alkaline secretion.

Possible objections are that the ulcer remains (removal may be unnecessary if the cause is removed) and pyloric obstruction, if functional will, of course, be corrected in pre-operative management; if organic, retention may be relieved by an associated pyloroplasty or gastro-duodenostomy.

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Connell, F.G. The noxious antral remnant in treatment of peptic ulcer of the duodenum. Amer. Jour. Dig. Dis. 17, 296–298 (1950). https://doi.org/10.1007/BF03002546

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Keywords

  • Peptic Ulcer
  • Duodenal Ulcer
  • Parietal Cell
  • Gastric Secretion
  • Subtotal Gastrectomy