Akamine Shinji

Itoh Shigehiko

Lin Souei

Ohe Hisakuni

Okada Daikiti

Soeda Osamu

Tokuyama Noboru

Tujino Naoyuki

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Acta Med. Nagasaki 33 : 174-178A Study of Gastric Ulcer and Cancer PerforationHisakuni OHE, Shigehiko ITOH, Noboru TOKUYAMA, Osamu SOEDA, Daikiti OKADA, Souei LIN, Shinji AKAMINE and Naoyuki TUJINODepertment of Surgery Emergency Medical Center,       Yahata Hospital, Kita-kyushu City     Received for publication, June 21, 1988       INTRODUCTION  Ten years have passed since the Emergency Medical Center was established. During this period 24 patients with gastric perforation, in-cluding 16 cases with gastric ulcer and eight cases with gastric cancer, were surgically opera-ted. A series of study was made with those 24 cases referring to their symptoms, preoperative diagnoses, modes of operation, prognosis (spe-cially as to death immediately after surgery), etc. Some knowledge obtained from the study is reported below. Gastric Ulcer Perforation  There were 83 patients surgically operated for gastric ulcer in the past 10 years, including 16 cases (19%), operated in emergency due to gas-tic ulcer perforation their age ranging from 15 to 77 years, 62.5 years on the average. They were operated hours to two days after incidence, 15.8 hours on the average. All of six cases (38%) known as gastric ulcer perforation by preopera-tive diagnosis had the history of gastric ulcer. One case out of six felt pain on the next day after gastric radioscopy, which suggests that perforation was induced by radioscopy. On abdominal X-ray films 13 cases (81 %) were free gas positive. Perforations were found at the cardia (C) in two cases, the body (M) in seven cases the antrum (A) in seven cases, all found on the anterior wall, except one case who had it on the posterior wall at the gastric angle. Gastrectomy was carried out in 11 cases, andsimple closure of perforation and drainage in five patients including two who had shocks be-fore the operation. When symptoms were im-proved, two cases had the secondary gas-trectomy. Postoperative complications were noted in two cases as postoperative wound infection, three cases as renal dysfunction, one case each as hepatic insufficiency and pneumo-nia. A patient operated two days after perfora-tion died of hepatic insufficiency on the 9th day after the operation. This is the only case of death caused by surgery. The one died of renal insufficiency 37 days after the operation was the patient who had some degrees of shock before the operation, and had an cardiac arrest during surgery, being endotoxin positive. After resuscitation, simple protection of the perforated area and peritoneal drainage were conducted, but withdrawal from shock was difficult after the operation, and died of renal insufficiency. Gastric Cancer Perforation  Out of 220 patients operated for gastric can-cer, patients (3.6%), four males and four fe-males had perforation. Their age at the time of operation ranged from 25 to 88 years, 61 years on the average. Out of three cases diagnosed as gastric cancer perforation preoperatively, two were already to be operated for gastric cancer, while another one was immediately bef ore the operation found perforation upon gastrographic radioscopy. Case No. 2 and 6 (Table 1) had severe pain immediately after gastroendoscopy, which was probably the cause of perforation.    Table 1. Preoperative Diagnosis, Operation and Prognosis in Gastric Cancer Perforation Case Age Sex Preperative Operative method Radicality Postoperative Prognosis No. diagnosis complication (Died of)                                   Gastrectomy (Primary)  1 67 M Gastric cancer Lymphnode dissection Curative Leakage of Cancer                perforation (after 1M) anastomose (21th month)  2 65 M Gastric cancer Omental wlapping Noncurative Renal After surgery                 perforation of perforated area insufficiency (9 days) 3 78 F Gastro intestinal tract Gastrectomy Noncurative Pneumonia Cancer                perforat on (7th month) 4 64 M Gastro intestinal tract Gastrectomy Noncurative Hepatic Cancer                 perforation insufficiency (3th month)  5 25 F Gastro intestinal tract Total gastrectomy Curative Hepatorenal After surgery                perforat on splenectomy insuffici cy (3 days)  6 66 F Gastric cancer Gastrectomy Curative Renal After surgery                perforation insufficiency (5 days) 7 88 F Gastro intestinal tract Simple closure Noncurative Renal After surgery                perforation of perforation insufficiency (17 days)                 Gastric ulcer Gastrectomy (Primary) Cancer8 36 F perforation Total gastrectomy Curative (-) (14th month)                                      (after 1M)All of them complained of increasing abdominal pain as one of clinical sysptoms, out of which five cases (6 3 %) revealed muscular defense and cases (63%) showed free gas on abdominal X-ray films. Perforations were noted in the ant-rum (A) in four cases, the body (M) in three cases and cardia (C) in one case. All of them were located on the anterior walls close to the lesser curvature of stomach. Mode of operation was selected according to perioperative condi-tions of the patients. Out of six gastrectomied cases the R2 operation was performed on three cases only, and two of them had the secondary operation after improvement of symptoms. Two patients out of eight could have drainage after simple protection of the perforated area, showing the curative resection rate of 5 0 %. All of them died from three days to 21 months after surgery, wherein death immediately after operation was noted at 50%, which is much higher as compared with 11.6% of postopera-tive death in gastric cancers without perfora-tion. As shown in Table 2, all these cancers were ulcerative type (three cases of Borrmann II and five cases of Borrmann III ), of highlyadvanced cancer at Stage ]II or further. As to the histology, there were three cases of poorly differectiated adenocarcinoma, three cases of signet ring cell carcinoma and one case each of moderately and well differentiated adenocarci-noma, revealing the majority of the poorly dif-ferentiated type. The histological development was noted to be upto ss ' with five cases. Type of Stage III or further was noted in only three cases except one case unknown in its histological advancement, revealing that there was a difference in development of cancer be-tween the histological and macroscopical find-ings. Postoperative Course of Gastric Ulcer and Gas-tric Cancer  In case of peritonitis caused by gastrointesti-nal perforation, anesthetic risks at emergency operation, endotoxin shocks caused by intra-peritoneal contamination, and bleeding are ex-pected at the early stage of prognosis. Table 3 shows a comparison of preoperative conditions in case of perforation between ulcer and cancer.  When age at the time of operation, time from   Table 2. Perforated area, and Macroscopical and Histological Advancement in Gastric Cancer Case Borrman's Macroscopic Histological Histological No. Perforated area Classification progress differentiation development of cancer  1 M (anterior wall) III StagelV signetring cell                                         P,, H,, S3 N, carcinoma ss- Y  2 M (anterior wall) II StagelV poorly differentiated                                      Po Ho S3 N2 adenocarcinoma - 3 A (anterior wall) II StagelV signetring cell                                        P0 H2 S2 N1 carcinoma ss- 7- 4 A (anterior wall) H1 StagelV poorly differentiated                                   P, H2 S3 N(3) adeno carcinoma se  5 C (anterior wall) III Stage III poorly differentiated                                        P0 Ho S2 N,, adenocarcinoma ss- y  6 A (anterior wall) III Stage lf well differentiated                                      PO Ho S2 N1 adenocarcinoma ss  7 A (anterior wall) II Stagelff moderately differentiated                                     P0 Ho S2 N1 adenocarcinoma s-,8  8 M (anterior wall) Stage III III Po Ho S2 N(2) signet ring cell carcinoma ss- y                Table 3. Gastric Ulcer and Cancer Perforations in Comparison                                    Gastric ulcer (16 cases) Gastric cancer (8 cases) Age at surgery 62.5±13.9 61.1±20.7 Time from incidence to surgery (hr) 15.8±13.1 15.6 ±23.0 Time for surgery (hr) 2.4±1.0 3.0±0.8 (anesthetic time) (3.4±1.1) (3.6±0.7) Perioperative bleeding (ml) 207±111* 381±226* Pre operative laboratory test  BT (°C) 36.5±0.5** 37.2±0.5**  WBC 9138±4251 10700±4171  TP (g/dl) 6.2±0.6 6.5±0.6  BUN (mg/dl) 32.3±16.9 19.5±6.5  Cre (mg/dl) 1.9±1.5 1.0±0.2 Death immediately after surgery (%) 1 (6.3%) 4 (50%)                                                                       * p<0 .05 ** p<0.1incidence of perforation to operation, time need-ed for operation and anesthesia, volume of bleeding, preoperative blood biochemical tests, etc., are compared between cancer and ulcer, no significant difference was observed except vol-ume of bleeding. Although two cases of pre-operative shock and one case of endotoxin pos-itive were observed in the patients with ulcer perforation, many more died immediately after the operation in cancer perforation.         DISCUSSION  Duodenal ulcer followed by gastric ulcer has been the most frequent cause of perforation in the upper gastrointestinal tract. Compared with such benign ulcer perforation the frequency of gastric cancer perforation is very low, reported as 0.15-2.89%.02) In the authors' clinic the fre-quency was 3.4%, much higher than the inci-dence in other reports, probably because many patients with acute celiopathy visit our institu-tion with the Emergency Medical Center.  It is very important in gastrointestinal per-forations that (1) a diganosis should be made as early as possible, (2) a mode of surgery should be selected to meet conditions of the patient, and (3) Peri-and postoperative management of peritonitis should be appropriate  There are many reports referring to the per-f ortion and surgery, as well as prognosis.,) It is stated that frequently endotoxin shock and bleeding shock occur in the patients 24 hours or more after the incidence, inducing unfavorable postoperative courses. The authors experienced that only one patient with gastric ulcer perf o-ration operated two days after incidence died immediately after surgery. Accordingly, not only for those free gas positive on X-ray films but even for those negative the respective sur-gery should be given without waste of time if perforation is suspected. Principally as a rou-tine, extensive gastrectomy should be applied to gastric ulcer. However, it is sometimes limit-ed to a simple closure of the perforated area or omental filling when a shock is advanced or blood pressure is unstable perioperatively. The authors had to conduct only simple closure on five cases out of 16, authough two cases of which had the secondary gastorectomy after improvement of conditions. The surgical opera-tion should be repeated positively when ulcer is hardly cured after the operation or hemor-rhage continues.  In gastric cancer perforation the radical cure must be considered simultaneously in addition to treatment of the perforated area. The R 2 operation is advisable, although it is offen lim-ited to noncurative resection, in most of those cases of advanced cancer. 4 ) In this study four patients out of eight (50%) were noncurative. However, development of cancer differs in cer-tain extent, as observed perioperatively and histologically, 5 ) therefore, even if it had been diagnosed as gastric ulcer perioperatively and noted as cancer postoperatively, or the opera-tion is limited to an extent of R 1 due to poor conditions, it is possible to expect the radical cure by conducting the secondary R2 operationafter improvement of the postoperative course. It may also be necessary to have the perforated area biopsied routinely during the operation in case of gastric perforation taking difficulties of the pre-and perioperative diagnosis of perf o-rated gastric cancer into account.6)   As the perf-and postoperative management of peritonitis, sufficient intraperitoneal wash-ing, drainage and treatment for the shock are required. In gastrointestinal perforations the authors used to conduct intraperitoneal wash-ing with 10,000 ml or more of physiological saline solution together with prophylactic treat-ment for renal and hepatic insufficiency after the operation.   Prognosis of perforated gastric cancer was very unfavorable, showing a high death rate immediately after the operation, although no difference in preoperative conditions was noted compared with that in perforated gastric ulcer. It is probably due to lack of readiness for the anesthetists and surgeons, who did not expect advanced cancer in addition to perforated gas-tric cancer.         CONCLUSION  The authors reported on 24 patients with gas-tric perforation treated in our clinic. All of them are surviving except one patient with gas-tric ulcer perforation who died after the opera-tion. On the contrary, in gastric cancer perfo-ration 50% of the patients died after poor post-operative courses. It was tried intensively to select a mode of operation to meet the general conditions of the patient taking the secondary operation into account.         REFERENCES  1) Nisi-ii M., SUGANO, T., KAsutitr, F. et al. : Per-   foration in Gastric Cancer, Stomach and    Intestines, 6 : 437-443, 1971. 2) NOMA, K., KATAOKA, K., YANIAGUCIII, Y. et al. ;    Gastric Cancer Perforation, Surgery, 26 : 756-  762, 1964. 3) TAKA,\,fi, M., KIMURA, M., TAKEUCHI, N. et al.    Lesions of Gastroduodenal perforation and    Their Treatment, Progress of Treatment in    Acute Abdominal Medicine, 6 (3) : 447-452,  1986. 4) YAMAGUCHI, A., HACEHSUKA, K., How, A. et al.   Acute Celiopathy due to Malignant Tumor-  A Study on Gastointestinal Perforations,   Journal of the Japan Society of Clinical   Surgery, 46 : 455-463, 1984. 5) IKE,DA, M., SAKAMOTO, H., TAMURA, H. et al.   A Clinicopathological Study of Gastric Can-  cer Perforation, Journal of the Japan Socie-  ty of Clinical Surgery, 47 : 343-347, 1985.6) S[EGERT T. A. and DONEGAN, W. L. : Acute Per-  foration of Gastric Carcinoma, Wisconsin   MED, J. 81:17-21, 1982

A Study of Gastric Ulcer and Cancer Perforation

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A Study of Gastric Ulcer and Cancer Perforation

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