BILLROTH OPERATION

From Big Medical Encyclopedia

BILLROTH OPERATION (T. Billroth, it is mute. the surgeon, 1829 — 1894) — a circular resection of distal department of a stomach with imposing of one of types duodenogastric (way Billroth-I) or gastrojejunal (way Billroth-II) of an anastomosis.

History

Use of operation of a resection of a stomach in clinic was preceded by a number of experiments on the animals who proved fiziol, admissibility of removal of a part of a stomach. In 1810 D. Merrem made a resection of peloric department of a stomach at several dogs with a favorable outcome. In 1876 at the request of Billroth Gussenbauer and Vinivarter (S. of Gussenbauer, A. Winiwarter) repeated Merrem's experiments. At these operations of a stump of a stomach and duodenum were anastomosed the end in the end at small curvature, a part of a gleam of a stump of a stomach at big curvature was taken in tightly.

In 1877 Billroth after successful sewing up of a wound of a stomach introduced the idea of a possibility of removal of the cancer-stricken site of a stomach.

In 1879 Mr. J. E. Pean, and in 1880 J. Rydygier made on in advance deliberate plan a resection of peloric department of a stomach concerning the stenosing cancer. In both cases patients died, at J. E. Pean — for the 4th days, at J. Rydygier — in 12 hours is after operation. Both J. E. Pean, and J. Rydygier connected a stump of a stomach to a duodenum an anastomosis the end in the end; J. E. Pean — without additional sewing up of a gleam of bodies, J. Rydygier — an anastomosis at small curvature after sewing up of a part of cross-section of a stump of a stomach from big curvature.

Fig. 1. The scheme of a resection of a stomach on the way Billroth-I.

On January 29, 1881 Billroth operated the woman of 43 years who had the stenosing cancer of peloric department of a stomach. The resection of piloro-antral department of a stomach throughout 14 cm was made. For recovery of a continuity went. - kish. a path at the first operation Billroth used the flow diagram offered by Ridiger: a part of a gleam of a stump of a stomach from big curvature was taken in, the duodenogastric anastomosis the end in the end is imposed at small curvature. A serious lack of this technique is stagnation of gastric contents at a bottom corner of a stump of a stomach with risk of development of insolvency of seams in this place. Therefore already at the third resection of a stomach made by Billroth on March 12, 1881 the flow diagram was changed them: the duodenogastric anastomosis the end in the end was created at big curvature, the gleam of a stump of a stomach is taken partially in from small curvature (fig. 1).

This simplest and rational technique of a resection of a stomach with a duodenogastric anastomosis gained the greatest distribution and is known as a resection of a stomach on the way Billroth-I.

A technique of a resection of a stomach with imposing of a duodenogastric anastomosis without preliminary special reduction of a gleam of a stump of a stomach it is reasonable to call by Pean's technique, and a technique of operation with formation of a gastroduodenal anastomosis at small curvature — way Ridiger.

In the same 1881 on this way 4 more patients are successfully operated; operations were executed by Billroth's pupils — Velfler and Common people (A. Wolfler, 8/IV; V. Czerny, 21/VI), and then Billroth (23/VII). All three operations are made concerning cancer; the fourth successful operation was made by Ridiger (21/XI) at a cicatricial and ulcer pyloric stenosis. However by 1882 only these 5 operations were successful, the others 17 (beginning from the first attempt of Pean) ended with the death of patients. Among them there was also the first resection of a stomach in Russia. It was made by M. K. Kitayevsky in St. Petersburg of 16/VI 1881 g; in 6 hours after operation of the patient died at the phenomena of cordial weakness. But at the beginning of 1882 (also in St. Petersburg)

N. V. Ekk successfully operated the patient of 35 years concerning cancer of the gatekeeper, having removed 7 cm of a stomach and 2 cm of a duodenum and anastomoznrovav their end in the end. The patient in good shape was shown to 13/V 1882 g at a meeting of Society of the Russian doctors. Ekk introduced the idea that in case of need an extensive resection when it is not possible to pull together stumps of a stomach and a duodenum, it is possible to sew up that and another tightly and to make gastroenterostomy (see).

For the first time transaction of the scheme offered by Ekk was executed by Billroth. 15/I 1885 g it operated the patient of 48 years concerning the stenosing cancer of output department of a stomach.

In the beginning Billroth planned to make palliative operation — imposing of a vperediobodochny gastroenteroanastomosis. However satisfactory condition of the patient by the end of this operation forced Billroth to change the initial plan and to finish operation with excision of the antral department of a stomach affected with a tumor with sewing up tightly a stump of a stomach and a duodenum. Billroth called this way of operation of a stomach atypical, unlike a classical way — a resection of a stomach with a duodenogastric anastomosis.

In 1898 on the 27th congress of the German surgeons two main methods of a resection of a stomach offered by Billroth to call in the ways — Billroth-I and Billroth-II were decided.

Prior to the beginning of 20 century the resection of a stomach was made very seldom, operation was followed by a high lethality. So, from 22 patients operated in Billroth's clinic for 1885 — 1889 as a result of operation 12 people died. Operation was made by hl. obr. at a cancer pyloric stenosis at sharply exhausted patients.

In process of development of abdominal surgery many authors offered various options of both the first, and second ways B. of the lake. It is described apprx. 30 modifications of each of ways of a resection of a stomach.

Modifications of the way Billroth-I (Bilrot-1)

Fig. 2. Some modifications of a resection of a stomach on the way Billroth-I: 1 — Peana; 2 — Billroth; 3 and 6 — Ridigera; 4 — Shemakera; 5 — A. Melnikova; 7 — Tomoda; 8 — Belflera; 9 — Babkoka; 10 — Gaberera.

Equipment. After the mobilization planned for removal of a part of a stomach by separation of a big epiploon from a cross colon (at cancer) or crossings of a gastrolic sheaf (at a peptic ulcer), crossings of an omentulum and bandaging of the corresponding vessels cross a stomach between clips on the upper bound of the resected site. The part which is subject to removal is closed a napkin and thrown back to the right. The stump of a stomach is sewn up with a two-storeyed seam, beginning from small curvature and leaving the opening corresponding to a gleam of a duodenum at big curvature. Having brought this not sewn up part of a stump of a stomach to a duodenum, sew their back walls noose serous and muscular sutures 5 — 10 mm lower than the gatekeeper. Having imposed a clip in the field of the last, cut a stomach from a duodenum directly over the line of these seams. Put a continuous catgut suture on walls of the sewed bodies for all circle of an anastomosis, and then noose serous and muscular sutures on a front wall of the last. This classical option (fig. 2, 2) is applied most often, despite its weak point — «a dangerous corner» in a joint of a linear seam at a stump of a stomach with circular on an anastomosis.

A weak point of operation on the way Billroth-I in any its modification is the possibility of discrepancy of seams of an anastomosis caused by rather poor blood supply of an initial part of a duodenum and lack of a serous cover on its back wall. These features of an anatomic structure of a duodenum promote development of insolvency of seams if the anastomosis is imposed with a tension. The possibility of absolutely free rapprochement of the sewed bodies is more important for success of intervention, than elimination of «a dangerous corner»; also have a talk it, on the one hand, popularity of classical option of the way Billroth-I, with another — use of this method only for the most economical piloro-antral resections.

All modifications of this way differ among themselves only with a technique of formation of a duodenogastric anastomosis. Depending on it they can be divided into four groups: a) the anastomosis forms on type the end in the end; b) on type the end sideways; c) on type a side in the end; d) on type a side sideways.

Ways of a resection with creation of various options of an anastomosis the end in the end are most widespread.

At the majority of options of this group of operations special receptions are necessary for elimination of discrepancy of width of cross-sections of a stomach and a duodenum. Only in Pean's modification at very limited resection of peloric department the stomach and a duodenum are anastomosed the end in the end without preliminary narrowing or a closure of a stomach stump (fig. 2,1).

At originally offered original technique of operation on the way Billroth-I a part of a gleam of a stump of a stomach from small curvature is taken in.

Shemaker (J. Scheemaker, 1911) offered option of operation with full excision of small curvature of a stomach, the created tubate stump is anastomosed with a duodenum (fig. 2, 4) the end in the end.

A. V. Melnikov (1941) for reduction of width of a stump of a stomach suggested to invaginate its small curvature in a gleam of a stomach (fig. 2, 5).

Ridiger suggested to create an anastomosis, using a part of a gleam of a stump of a stomach at small curvature (fig. 2, 3). This way was used by other surgeons. In the subsequent operations Ridiger made excision of a corner of a stump of a stomach at big curvature for prevention of stagnation of food in the formed pocket of a stump of a stomach (fig. 2, 6).

Tomoda (M. of Tomoda, 1961) for delay of evacuation from a stump of a stomach recommended the similar technique of formation of a duodenogastric anastomosis at small curvature added with formation of a spur (fig. 2, 7).

Velfler (1881), Babkok (W. W. Babcock, 1926) suggested to create an anastomosis in a middle part of a stump of a stomach, taking in a part of its gleam as from big, and small curvature (fig. 2, 8 and 9). These modifications did not gain distribution to force of the formed two unreliable sites in places of a joint of three seams from small and big curvature of a stump of a stomach.

A number of the modifications of operation on the way Billroth-I allowing to eliminate discrepancy of the anastomosed bodies without sewing up of a part of a gleam of a stump of a stomach is offered. Gaberer's method is most known among them (H. Haberer, 1933). At this way by imposing of the corrugating seams the gleam of a stump of a stomach is narrowed up to the width of a duodenum then between them the anastomosis the end in the end (fig. 2, 10) is imposed.

Also other methods different from Gaberer's technique of hl were offered. obr. in the way of imposing of the corrugating seams. Gaberer's modification and it similar are applied seldom owing to often arising narrowing of an anastomosis.

Fig. 3. Modifications of a resection of a stomach with a duodenogastric anastomosis the end sideways: 1 — Gaberer, Finney; 2 — Finsterera.

From options of operation with a gastroduodenal anastomosis the end sideways gained the greatest distribution the way offered by Gaberer in 1922 and irrespective of it Finney (J. M. T. Finney) in 1924. At this way the gleam of a stump of a stomach is anastomosed with a front wall of a vertical part of a duodenum after sewing up tightly of her stump (fig. 3, 1). In Finsterer's modification (H. Finsterer, 1929) the anastomosis is imposed near big curvature of a gleam of the stump of a stomach which is partially taken in from small curvature (fig. 3, 2). This option of operation gained the greatest distribution. This method allows to create a duodenogastric anastomosis with its functional advantages at the sharp cicatricial changes of an initial part of a duodenum excluding a possibility of creation of a duodenogastric anastomosis the end in the end.

The modifications of operation on the way Billroth-I offered by a number of authors with creation of a duodenogastric anastomosis on type a side in the end and a side sideways did not gain distribution owing to the increased risk of operation because of a possibility of development of insolvency of seams not only an anastomosis, but also the stumps of a stomach and a duodenum which are taken in tightly.

Did not find broad application and various type the segmented resections of a stomach offered in different years by various authors [Mikulich, 1897; Vangensten (O. Wangensteen), 1940, etc.]. These options of a resection of a stomach at which the peloric press is not removed it is impossible to carry the lake to B. The majority of these methods was offered for the purpose of local excision of stomach ulcer and was based on the wrong idea of stomach ulcer as purely local pathological process. Some of the offered methods of a segmented resection of a stomach are used also in a crust, time, but according to very limited special indications, quite often by force when it is impossible to execute fuller operation. In particular, the segmented resection of a stomach can be used at benign tumors of a stomach if it is not possible to execute enucleation of a tumor. According to forced indications the segmented resection of a stomach is sometimes made at the bleeding stomach ulcer and at very serious condition of the patient. In this case operation pursues the aim only of a stop of bleeding, but not radical treatment of a peptic ulcer. Some surgeons combine this intervention with vagisection that provides impact on pathogenetic mechanisms of a peptic ulcer.

Modifications of the way Billroth-II (Bilrot-2)

the resection of a stomach is Most widespread in modification of the Steward of the household — Finsterera.

Technology of operation on a way Billroth - II (modification of the Steward of the household — Finsterera).

Usual midsection from a xiphoidal shoot to a navel in need of a high resection can be prolonged up to a midsternum with a bypass or a resection of a xiphoidal shoot.

Mobilization of the part of a stomach which is subject to removal is made, as well as at the operation Billroth-I, but in big limits. On small curvature alloy the right and left gastric vessels, on big — right and left gastrostuffing. At a carcinoma of the stomach whenever possible extensive resection if it is necessary — subtotal is carried out; the struck part of a stomach is removed with all omentulum, a gastropancreatic sheaf and a big epiploon. It is separated from a cross colon, without damaging its vessels.

At a peptic ulcer two distal thirds of a stomach — a zone of its active secretion are subject to removal. For this purpose the line of cutting off of the deleted part shall be planned on big curvature for 1 — 2 cm above approach to a wall of a stomach of the lower branch of the left gastroomental artery, and on small — on border of its upper and average third. Having imposed clips, cut the mobilized stomach from a duodenum directly below the gatekeeper and her stump sew up two - a three-storyed seam. If necessary resort to more difficult methods of closing of a stump. Then the part of a stomach which is subject to removal is cut between clips; the stump of a stomach is taken in from small curvature, leaving at big curvature an opening for an anastomosis approximately in 1/3 width of a stump. The stitch is put at first continuous pedicellate (catgut) for a prelum of vessels of a gastric wall, then immersed its noose serous and muscular sutures (silk). Having made an opening in the avascular site of mesocolon, at its root, carry out a short loop of a small bowel through this window and at distance of 12 — 15 cm from plica duodenojejunalis anastomose from stumps of a stomach. Before opening of a gleam of a gut put noose seroznomyshechny sutures silk on a back semi-circle of future anastomosis, then open a gut, noose serous and muscular sutures on its front wall put a continuous catgut suture on all circle of an anastomosis and, at last. Such type of a two-storeyed seam is most accepted.

Having finished imposing of an anastomosis, hem the bringing piece of a gut to a stump of a stomach several noose sutures — from small curvature to an anastomosis; this hemmed part shall have approximately the same length, as not hemmed (from plica duodenojejunalis to a stump of a stomach), i.e. 6 — 7 cm. The stump of a stomach is strongly fixed not resolving seams; at small curvature — by the remains of an omentulum and to a back pristenochny peritoneum, and at big — to edges of an opening in mesocolon, at its root, taking a wall of a stomach it is possible above an anastomosis. The abdominal cavity is sewn up tightly.

The set of the existing modifications of a resection of a stomach on the second way of Billroth differ from each other in various combination of several main features of designing of a gastrojejunal anastomosis. Basic structural elements of operation following: a) type of a gastrojejunal anastomosis (the end sideways, the end in the end, a side sideways, a side in the end); b) an arrangement of an anastomosis on a stump of a stomach (on a front wall, on a back wall, on big curvature); c) use for an anastomosis of all section of a stump of a stomach, a part it on big curvature, speak rapidly it on small curvature, a middle part of cross-section of a stump of a stomach; d) the direction of a vermicular movement of the loop of a jejunum anastomosed with a stomach (isoperistaltic, antiperistaltic); e) an arrangement of a loop, anastomozirovanny with a stomach, in relation to a cross colon (pozadiobodochny, vperediobodochny); e) existence and type of additional soustiya between a gut, bringing and taking away parts anastomozirovanny with a stomach (a side sideways, the end sideways).

The first operation on the way Billroth-II was made by force as successful escaping of the created situation.

Fig. 4. Some modifications of a resection of a stomach on the way Billroth-II: 1 — original Billroth; 2 — Krenleyna; 3 — Eyzelsberg; 4 — the Steward of the household; 5 — Finsterera; 6 — Reykhelya and Polya; 7 — Balfura; 8 — Reykhelya; 9 — Ru; 10 — Moynikhena.

Further the initial version of this operation (fig. 4, 1) was not widely adopted. This way has an essential shortcoming — formation of a blind pocket between a gastrointestinal anastomosis and the stump of a stomach which is taken in tightly that complicates evacuation from a stump of a stomach and increases risk of development of insolvency of seams. However the flow diagram by an original technique of Billroth has some advantages during the performance of a resection of a stomach using staplers.

The idea of use for a gastrojejunal anastomosis of cross-section of the stomach formed after a resection belongs to R. Kronlein who for the first time executed this operation in 1887 (fig. 4, 2).

The idea of use for an anastomosis with a jejunum of partially taken in stump of a stomach belongs to Gakker (V. Hacker, 1885). This idea is for the first time carried out in practice by Billroth's assistant Eyzelsberg (A. F. Eiselsberg) in 1889 (fig. 4, 3). The steward of the household (M. of F. Hofmeister, 1896) during the performance of a resection of a stomach widely excised small curvature, took in 2/3 gleams of a stump of a stomach from small curvature, the bringing loop was fixed to the taken-in part of a stump of a stomach (fig. 4, 4). The similar technique was applied by Vilms (M. of Wilms, 1911) and S. I. Spasokukotsky (1911). The taking-away loop of a jejunum was hemmed to edges of openings in a mesentery of a cross colon. Improvement of the way Billroth-II is in many respects obliged to works of the Austrian surgeon Finsterer. Features of operation on Finsterer's method following: the resection of a stomach is made on the vertical line with higher crossing of small curvature, the gastrojejunal anastomosis is created with very short loop of a jejunum, at distance

of 4 — 6 cm from duodenal leanly - an intestinal bend (plica duodenojejunalis), carried out pozadiobodochno; the bringing loop is hemmed to the taken-in part of a stump and small curvature of a stomach; rotation of the loop of a jejunum anastomosed with a stomach is made nek-paradise; upon termination of operation the stump of a stomach is hemmed to edges of an opening in a mesentery of a cross colon above an anastomosis (fig. 4, 5). Finsterer made the first operation on such technique in 1911 and described in 1914.

This option of the way Billroth-II under the name of a resection of a stomach on the Steward of the household — to Finsterer gained the greatest recognition and is widely applied in a crust, time.

At one time enough the method of a resection of a stomach according to F. Reichel was widely adopted — It is full. The first message on this option was made by F. Reichel in 1908. In 1910 Polya (E. A. Polya) showed the patient operated by this method (fig. 4, 6) in surgical society of Budapest.

In 1927 Balfur (D. Page of Balfour) for prevention of development of a vicious circle suggested to add the technique of a resection of a stomach offered by Krenleyn with an anastomosis between the bringing and taking away intestinal loops located vperediobodochno. This option of operation is known as Balfur's (fig. 4, 7) way. With the same purpose F. Reichel (1921) is offered to impose an anastomosis between the bringing and taking away loops at a pozadiobodochny arrangement of an intestinal loop, anastomozirovanny with a stomach (fig. 4, 8).

For reduction of a pelting of contents of a stomach in the bringing loop the option of operation with a Y-shaped interintestinal anastomosis across Ru at a pozadiobodochny arrangement of an intestinal loop (fig. 4, 9) is applied. Also other modifications with use of a Y-shaped interintestinal anastomosis were offered (A. A. Opokin, 1938; I. A. Ageenko, 1953).

With the purpose to slow down evacuation from a stump of a stomach Moynikhen (V. of G. Moynihan, 1928) suggested to create a gastrojejunal anastomosis with an arrangement of the taking-away loop at small curvature of a stomach at a vperediobodochny arrangement of an intestinal loop (fig. 4, 10).

This modification did not gain distribution to force of frequent disturbance of evacuation from a stump of a stomach and a pelting of gastric contents in the bringing loop.

In a crust, B.'s time of the lake in this or that modification treats the most widespread intervention in abdominal surgery. Indications and contraindications to use of the first and second ways of operation are rather accurately defined.

Indications

the Way Billroth-I is shown most often at the high-quality (cicatricial) pyloric stenoses which arose after healing of a peloric ulcer.

At a carcinoma of the stomach it is not necessary to apply a way even in case of its technical feasibility; it limits limits of a resection and, therefore, does not provide due radicalism of intervention.

In case of a recurrent tumor in retropilorichesky limf, nodes there is always a risk of a prelum of a duodenogastric anastomosis with disturbance of evacuation from a stump of a stomach.

From the middle of 20 century of the indication to operation extended due to its use in a combination with vagisection (see) at surgical treatment of an ulcer of a duodenum. Make an economical piloro-antral resection (sometimes only pylorectomy or only antrectomy) as the additional intervention draining a stomach, i.e. providing free evacuation of its contents after vagisection (see. Peptic ulcer , surgical treatment).

The way Billroth-II in this or that modern modification shall be applied in all those numerous cases when it is impossible to be limited to an economical piloro-antral resection. It belongs to the following interventions: concerning stomach ulcer when for efficiency of operation it is necessary to remove the most part of actively cosecreting zone of the last; concerning polyps of a stomach, at their localization out of the limits allowing an economical resection; concerning heavy cicatricial deformations of a stomach («hourglasses» and so forth). Operation on the way Bilrot-2 is, as a rule, obligatory at malignant new growths of a stomach irrespective of technical capability to execute operation on the way Billroth-I.

Only cancer of cardial department is subject to operation on a special technique (see. Stomach , cancer), in all other cases of high localization of a tumor a resection on the way Billroth-II can be expanded to a high subtotal resection with a gastrojejunal anastomosis. At last, on the way Billroth-II the resection is applied at ulcers of a duodenum, unavailable to removal; this so-called resection for switching off offered by Finsterer (1918) provides special ways of processing and closing of a stump of a duodenum. A resection of a stomach «for switching off», offered by Finsterer, it is not necessary to confuse to modification of the operation Billroth-II which is also offered by Finsterer in 1914.

In recent years rather broad application at a resection of a stomach is found staplers (see); they accelerate intervention and facilitate preservation of an asepsis. Details of the technology of operation, an order of training of the patient for B. the lake and possible complications of the postoperative period — see the Stomach, operations. Late complications — see. Postgastrorezektsionny syndrome .

The lethality after B. of the lake in its various modifications, on statisticians of 1964 — 1973, fluctuates from the tenth shares of percent to 3 — 7% depending on the disease which was the cause for intervention and from a condition of patients. The lethality at far come carcinoma of the stomach is highest.


The bibliography

Bal V. M. Rezektion of a stomach on the way Billroth-I — Gaberera, Astrakhan, 1934, bibliogr.; Berezov E. JI. Surgery of a stomach and duodenum, Gorky, 1950, bibliogr.; Busalov A. A. A resection of a stomach at a peptic ulcer, M., 1951, bibliogr.; W about 1 f 1 e of of A. Vyrezyvaniye of cancer of a pylorus, the lane with it., SPb., 1881; Ganichkin A. M. and Reznik S. D. Methods of recovery of a gastrointestinal continuity at a resection of a stomach, D., 1973, bibliogr.; To at to about sh V. PI. A resection of a stomach at a peptic ulcer with a mechanical seam, Gorky, 1968, bibliogr.; Litt-m and N of N And. Belly surgery, the lane with it., Budapest, 1970; P at with and N about in A. A. Rezektion of a stomach, L., 1956; it, About the reasons of so-called diseases of the resected stomach, Vestn, hir., t. 109, No. 8, page 6, 1972; Spasokukotsky S. I. Resection of a stomach as radical and palliative operation, Hir. arkh. Velyaminova, prince 5, page 739, 1912; it, Works, t. 2, page 107, M., 1948; In and 1 f about u of of D. Page of The technique of partial gastrectomy for cancer of the stomach, Surg. Gynec. Obstet., v. 44, p. 659, 1927; Billroth T. Offenes Schreiben an Herrn L. Wittelshofer, Wien. med. Wschr., S. 161, 1881; it, t) ber 124 vom Nowember 1878 bis Juni 1890 in mei-ner Klinik und Privatpraxis ausgefiihrte Resektionen am Magen-und Darmcanal Gastro-Enterostomien und Narbenlosungen wegen chronischer Krankheitsprocesse, Wien, klin. Wschr., S. 625, 1891; F i n s t e-r e r H. Zur Technik der Magenresektion, Dtsch. Z. Chir., Bd 127, S. 514, 1914; it, Ausgedehnte Magenresektion bei Ulcus duodeni statt der einfachen Duodc-nalresektion bzw. Pylorusausschaltung, Zbl. Chir., Bd 45, S. 434, 1918; Gueullette R. Chirugie de l’estomac P., 1956; Haberer H. Meine Technik aer Magen-resection, Munch, med. Wschr., S. 915, 1933; H o 1 1 e F. Spezielle Magenchirur-gie, B. u. a., 1968, Bibliogr.; Maingot R. Abdominal operations, L., 1961; Moynihan B. Some problems in gastric surgery, Brit. med. J., v. 2, p. 1021, 1928, bibliogr.; P 6 a n J. De l’ablation des tumeurs de l’estomac par la gastrecto-mie, Gaz. Hop. (Paris), p. 473, 1879; P ό 1 at an E. Zur Stumpfversorgung nach Magenresektion, Zbl. Chir., S. 892, 1911; R e i with h e 1, Zum Stumpfversorgung nach Magenresektion, ibid., S. 1401; R at d y-g i e r, Die erste Magenresection beim Ma-gengeschwiir, Berl. klin. Wschr., S. 39, 1882.

And. B. Gulyaev, A. A. Rusanov.

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