The problem of recurrent peptic ulcer after operation.

General Considerations Although little enough is known about the cause of the onset of duodenal ulceration, there is no doubt that its persistence is associated with increased acidity of the gastric juice. This is a physical character of the individual, based upon an excess of acid-secreting mucosa in the stomach. Failure to reduce this acidity is the chief cause of post-operative ulceration at the anastomosis, since the jejunum is even more vulnerable to acid chyme than the duodenum. Thus in experimental animals gastro-jejunal ulcers can be produced by simply by-passing the alkaline juices of the duodenum into the intestine beyond the gastric anastomosis. The counterpart of this arrangement in human surgery is a gastro-enterostomy made with a Roux 'Y' loop, or the addition of an entero-anastomosis to an otherwise standard operation. Both these procedures nearly always result in ulceration at the stoma and have long since been discarded in practice. When a gastro-enterostomy is performed for duodenal ulcer, the acid juice is diverted away from the lesion and it promptly heals. The operation may, of course, result in a further erosion at the anastomosis, whereby the patient will be in worse case than before, but the ulcer in the duodenum will always heal. Radiologists, unable in some cases to demonstrate the real cause of the trouble at the stoma, and observing the old duodenal deformity, are apt to interpret this as persistence of the ulcer there. This is practically never so; only complete stenosis of the stoma will cause a reactivation of the original duodenal lesion after gastro-enterostomy. Gastric ulcers are not generally associated with increased secretion or acidity of peptic juice, and it seems clear that this is the reason for their remarkable immunity from trouble at the anastomosis after operation. This applies not only to partial gastrectomy for gastric ulcer, but also to the very effective operation of gastro-enterostomy for ' hand-bag' deformity of the stomach with stasis, due to extensive contraction of the lesser