胃潰瘍の治療の検討―外科的立場から

Evaluation of Surgical Treatment for Chronic Gastric Ulcer

　最近は診断技術の向上により胃潰瘍と胃癌の確実な鑑別が容易となり，胃潰瘍に対する内科的治療法が積極的に行われている．たしかに20年前に比較すれば胃潰瘍の手術症例数はやや少なくなっているが，大変少なくなったというほどでもない．五ノ井¹⁾によれば胃潰瘍の平均治癒率は29％と1/3を越えていない．しかも原²⁾によれば内科的治療により治癒した潰瘍も11～12年を経過するうち71％に再発がみられるという．この原の報告から累積再発率を推定すると，もし20年の経過を観察しえたとしたらその再発率は90％に達するという¹⁾．このような報告からみると胃潰瘍は治りにくいものが多く，いったん治癒しても長い経過の中にはほとんど再発するということになる．この辺が今日なお胃潰瘍手術症例数に極端な減少のみられない理由であろう．

　ところで手術する側からみて胃潰瘍と十二指腸潰瘍の手術例数に変わりはないだろうか．Table 1は教室における手術症例数であるが，胃潰瘍に対し十二指腸潰瘍に共存潰瘍を加えたものの症例数の比は1961～65年では2：1であるのに対し1971～77年では1：1となっている．これは著者らの施設だけではなく本邦における最近の一般的傾向のようである．

　A total of 1036 patients have been operated upon for chronic gastric and duodenal ulcer at the Niigata University Hospital in the past 17 years. Gastric ulcer was seen in 631 cases (60.9%), duodenal ulcer in 317 (30.5%), and coexisting gastroduodenal ulcer in 89 (8.6%).

　Selective surgery has been applied as a policy to each of the cases with gastric or duodenal ulcer in order to obtain suitable reduction of gastric acid serection and satisfactory preservation of gastric function along with no recurrent ulcer. Selective surgery has been performed in 631 consecutive cases with chronic ulceration of the stomach. Our standard operative procedures are (1) proximal gastrectomy with vagotomy, (2) segmental gastrectomy with or without vagotomy, (3) conventional partial gastrectomy (70% distal gastric resection), (4) antrectomy with or without vagotomy, and (5) the others.

　Overall operative mortality was 0.95%, although it was 0.3% in the recent 12 years. Recurrence was seen in one patient (recurrence rate＝0.16%) who had undergone segmental gastrectomy with vagotomy. Incomplete vagotomy was the cause of recurrent ulcer in this case, which was cured by complete revagotomy. Postoperative disturbance (dumping syndrome, weight loss, diarrhea and anemia) were fewer in the patients who underwent segmental gastrectomy with selective proximal vagotomy than in those with proximal gastrectomy, conventional partial gastrectomy and antrectomy with or without selective gastric vagotomy.

　As to the postoperative alterations of serum vitamin B12, Schilling's test and intrinsic factor in gastric juice, there was no statistical difference between conventional partial gastrectomy, segmental gastrectomy with vagotomy and antrectomy with vagotomy. It is suggested that segmental gastrectomy be applied for high-located gastric ulcer, because disturbance of vitamin B₁₂ absorption was seen in the patients who had subtotal gastrectomy.

　Postoperative level of serum calcium concentration showed more distinct decrease in the patients who had subtotal gastrectomy or conventional partial gastrectomy with Billroth-II type than in those with Billroth-Ⅰ. It is supposed that operations which bypass the duodenum and proximal portion of the jejunum decrease intestinal absorption of calcium.

　To get better results, several operative procedures with no gastric resection might be tried, although the small-extent gastric resection, with or without vagotomy, remains the most theoretically advantageous and clinically proven treatment of gastric ulcers.