Surgical treatment of peptic ulcerations: Billroth I method

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The limitations, dangers and indications of the various methods of Billroth I anastomosis for duodenal ulcer have been pointed out. The technique of a typical Haberer modification of a Billroth I end-to-end procedure has been described. None of the variations of the Billroth I method should be used where there is a malfunction or stasis of the duodenum. An orientation of the anatomical relationships is of paramount importance before a resection of the duodenal ulcer is undertaken. The relationship of the part of the duodenum to be removed to the pancreatic duct, hepatic artery, the portal vein and the pancreas should be definitely established before a resection of the duodenum is undertaken. For this reason, in the obviously difficult cases, the common duct should be isolated and identified. If one anticipates an injury to the pancreas or the pancreatico-duodenal artery it is inadvisable to continue with a radical resection of the duodenum. One should proceed with an exclusion resection operation according to Finsterer. The infrapapillary end-to-side type of Billroth I operation is contraindicated on account of the frequency of high intestinal obstruction from too extensive mobilization of the duodenum and kinking at the mesenteric root. The Haberer-Finney end-to-side modification of the Billroth I method is characterized by frequent postoperative vomiting. It should be practiced only under exceptionally favorable anatomical conditions. Where the head of the pancreas is too large, or where the individual is too fat, and where the mobilization of the duodenum appears to be difficult, this method is contraindicated. Eleven cases of the Haberer modification of Billroth I end-to-end and 3 cases of the terminolateral anastomosis of Billroth I procedures are recorded with no mortality and no morbidity. In this group are included 2 cases of jejunal ulceration following gastroenterostomy and also 3 acutely bleeding duodenal ulcers. The Billroth I end-to-end modification by Haberer is anatomically and physiologically a correct operation and gives excellent results. In a larger series of cases Finsterer's modification of Billroth II method will give better functional results and a lower mortality. An understanding of the physiological principles and anatomical relations and the details of technique in the resection of the duodenum and in the completion of the Billroth I anastomosis for duodenal ulcer is of utmost importance. The mortality can be reduced when only those ulcers are attacked which can be removed with safety. For those ulcers which are dangerous to remove some other surgical procedure should be substituted.